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Abstract
Levosimendan is an inodilator that promotes cardiac contractility primarily through calcium sensitization of cardiac troponin C and vasodilatation via opening of adenosine triphosphate–sensitive potassium (KATP) channels in vascular smooth muscle cells; the drug also exerts organ-protective effects through a similar effect on mitochondrial KATP channels. This pharmacological profile identifies levosimendan as a drug that may have applications in a wide range of critical illness situations encountered in intensive care unit medicine: hemodynamic support in cardiogenic or septic shock; weaning from mechanical ventilation or from extracorporeal membrane oxygenation; and in the context of cardiorenal syndrome. This review, authored by experts from 9 European countries (Austria, Belgium, Czech republic, Finland, France, Germany, Italy, Sweden, and Switzerland), examines the clinical and experimental data for levosimendan in these situations and concludes that, in most instances, the evidence is encouraging, which is not the case with other cardioactive and vasoactive drugs routinely used in the intensive care unit. The size of the available studies is, however, limited and the data are in need of verification in larger controlled trials. Some proposals are offered for the aims and designs of these additional studies.
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352
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Tuinman PR, Jonkman AH, Dres M, Shi ZH, Goligher EC, Goffi A, de Korte C, Demoule A, Heunks L. Respiratory muscle ultrasonography: methodology, basic and advanced principles and clinical applications in ICU and ED patients-a narrative review. Intensive Care Med 2020; 46:594-605. [PMID: 31938825 PMCID: PMC7103016 DOI: 10.1007/s00134-019-05892-8] [Citation(s) in RCA: 138] [Impact Index Per Article: 27.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 12/02/2019] [Indexed: 02/06/2023]
Abstract
Respiratory muscle ultrasound is used to evaluate the anatomy and function of the respiratory muscle pump. It is a safe, repeatable, accurate, and non-invasive bedside technique that can be successfully applied in different settings, including general intensive care and the emergency department. Mastery of this technique allows the intensivist to rapidly diagnose and assess respiratory muscle dysfunction in critically ill patients and in patients with unexplained dyspnea. Furthermore, it can be used to assess patient-ventilator interaction and weaning failure in critically ill patients. This paper provides an overview of the basic and advanced principles underlying respiratory muscle ultrasound with an emphasis on the diaphragm. We review different ultrasound techniques useful for monitoring of the respiratory muscle pump and possible therapeutic consequences. Ideally, respiratory muscle ultrasound is used in conjunction with other components of critical care ultrasound to obtain a comprehensive evaluation of the critically ill patient. We propose the ABCDE-ultrasound approach, a systematic ultrasound evaluation of the heart, lungs and respiratory muscle pump, in patients with weaning failure.
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Affiliation(s)
- Pieter R Tuinman
- Department of Intensive Care Medicine, Amsterdam UMC, Location VUmc, Amsterdam, The Netherlands.,Amsterdam Leiden Intensive Care Focused Echography (ALIFE), Amsterdam, The Netherlands
| | - Annemijn H Jonkman
- Department of Intensive Care Medicine, Amsterdam UMC, Location VUmc, Amsterdam, The Netherlands
| | - Martin Dres
- Department of Pulmology and Medical Intensive Care, APHP Sorbonne Université, Pitié-Salpêtrière Hospital, Paris, France
| | - Zhong-Hua Shi
- Department of Intensive Care Medicine, Amsterdam UMC, Location VUmc, Amsterdam, The Netherlands.,Department of Critical Care Medicine, Capital Medical University, Beijing Tiantan Hospital, Beijing, 100050, China
| | - Ewan C Goligher
- Interdepartmental Division of Critical Care Medicine and Department of Medicine, University of Toronto, Toronto, ON, Canada.,Critical Care Medicine, University Health Network, Toronto General Hospital, Toronto, ON, Canada
| | - Alberto Goffi
- Interdepartmental Division of Critical Care Medicine and Department of Medicine, University of Toronto, Toronto, ON, Canada.,Division of Critical Care Medicine, Department of Medicine, St. Michael's Hospital, Toronto, ON, Canada
| | - Chris de Korte
- Department of Radiology, Radboud UMC, Nijmegen, The Netherlands
| | - Alexandre Demoule
- Department of Pulmology and Medical Intensive Care, APHP Sorbonne Université, Pitié-Salpêtrière Hospital, Paris, France
| | - Leo Heunks
- Department of Intensive Care Medicine, Amsterdam UMC, Location VUmc, Amsterdam, The Netherlands.
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353
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Zhou XL, Wei XJ, Li SP, Ma HL, Zhao Y. Lung-protective ventilation worsens ventilator-induced diaphragm atrophy and weakness. Respir Res 2020; 21:16. [PMID: 31924204 PMCID: PMC6954632 DOI: 10.1186/s12931-020-1276-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 01/02/2020] [Indexed: 02/07/2023] Open
Abstract
Background Lung–protective ventilation (LPV) has been found to minimize the risk of ventilator–induced lung injury (VILI). However, whether LPV is able to diminish ventilator–induced diaphragm dysfunction (VIDD) remains unknown. This study was designed to test the hypothesis that LPV protects the diaphragm against VIDD. Methods Adult male Wistar rats received either conventional mechanical (tidal volume [VT]: 10 ml/kg, positive end–expiratory pressure [PEEP]: 2 cm H2O; CV group) or lung-protective (VT: 5 ml/kg, PEEP: 10 cm H2O; LPV group) ventilation for 12 h. Then, diaphragms and lungs were collected for biochemical and histological analyses. Transcriptome sequencing (RNA–seq) was performed to determine the differentially expressed genes in the diaphragms between groups. Results Our results suggested that LPV was associated with diminished pulmonary injuries and reduced oxidative stress compared with the effects of the CV strategy in rats. However, animals that received LPV showed increased protein degradation, decreased cross–sectional areas (CSAs) of myofibers, and reduced forces of the diaphragm compared with the same parameters in animals receiving CV (p < 0.05). In addition, the LPV group showed a higher level of oxidative stress in the diaphragm than the CV group (p < 0.05). Moreover, RNA–seq and western blots revealed that the peroxisome proliferator–activated receptor γ coactivator–1alpha (PGC–1α), a powerful reactive oxygen species (ROS) inhibitor, was significantly downregulated in the LPV group compared with its expression in the CV group (p < 0.05). Conclusions Compared with the CV strategy, the LPV strategy did not protect the diaphragm against VIDD in rats. In contrast, the LPV strategy worsened VIDD by inducing oxidative stress together with the downregulation of PGC–1α in the diaphragm. However, further studies are required to determine the roles of PGC–1α in ventilator-induced diaphragmatic oxidative stress.
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Affiliation(s)
- Xian-Long Zhou
- Emergency Center, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuhan, 430071, Hubei, China
| | - Xiao-Jun Wei
- Emergency Center, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuhan, 430071, Hubei, China
| | - Shao-Ping Li
- Emergency Center, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuhan, 430071, Hubei, China
| | - Hao-Li Ma
- Department of Biological Repositories, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuhan, 430071, Hubei, China
| | - Yan Zhao
- Emergency Center, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuhan, 430071, Hubei, China.
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354
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Saccheri C, Morawiec E, Delemazure J, Mayaux J, Dubé BP, Similowski T, Demoule A, Dres M. ICU-acquired weakness, diaphragm dysfunction and long-term outcomes of critically ill patients. Ann Intensive Care 2020; 10:1. [PMID: 31900667 PMCID: PMC6942110 DOI: 10.1186/s13613-019-0618-4] [Citation(s) in RCA: 78] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2019] [Accepted: 12/16/2019] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Intensive care unit (ICU)-acquired weakness and diaphragm dysfunction are frequent conditions, both associated with poor prognosis in critically ill patients. While it is well established that ICU-acquired weakness severely impairs long-term prognosis, the association of diaphragm dysfunction with this outcome has never been reported. This study investigated whether diaphragm dysfunction is associated with negative long-term outcomes and whether the coexistence of diaphragm dysfunction and ICU-acquired weakness has a particular association with 2-year survival and health-related quality of life (HRQOL). METHODS This study is an ancillary study derived from an observational cohort study. Patients under mechanical ventilation were enrolled at the time of their first spontaneous breathing trial. Diaphragm dysfunction was defined by tracheal pressure generated by phrenic nerve stimulation < 11 cmH2O and ICU-acquired weakness was defined by Medical Research Council (MRC) score < 48. HRQOL was evaluated with the SF-36 questionnaire. RESULTS Sixty-nine of the 76 patients enrolled in the original study were included in the survival analysis and 40 were interviewed. Overall 2-year survival was 67% (46/69): 64% (29/45) in patients with diaphragm dysfunction, 71% (17/24) in patients without diaphragm dysfunction, 46% (11/24) in patients with ICU-acquired weakness and 76% (34/45) in patients without ICU-acquired weakness. Patients with concomitant diaphragm dysfunction and ICU-acquired weakness had a poorer outcome with a 2-year survival rate of 36% (5/14) compared to patients without diaphragm function and ICU-acquired weakness [79% (11/14) (p < 0.01)]. Health-related quality of life was not influenced by the presence of ICU-acquired weakness, diaphragm dysfunction or their coexistence. CONCLUSIONS ICU-acquired weakness but not diaphragm dysfunction was associated with a poor 2-year survival of critically ill patients.
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Affiliation(s)
- Clément Saccheri
- Service de Pneumologie, Médecine intensive - Réanimation (Département "R3S"), AP-HP, Sorbonne Université, Groupe Hospitalier Universitaire Pitié-Salpêtrière Charles Foix, 75013, Paris, France
| | - Elise Morawiec
- Service de Pneumologie, Médecine intensive - Réanimation (Département "R3S"), AP-HP, Sorbonne Université, Groupe Hospitalier Universitaire Pitié-Salpêtrière Charles Foix, 75013, Paris, France
| | - Julie Delemazure
- Service de Pneumologie, Médecine intensive - Réanimation (Département "R3S"), AP-HP, Sorbonne Université, Groupe Hospitalier Universitaire Pitié-Salpêtrière Charles Foix, 75013, Paris, France
| | - Julien Mayaux
- Service de Pneumologie, Médecine intensive - Réanimation (Département "R3S"), AP-HP, Sorbonne Université, Groupe Hospitalier Universitaire Pitié-Salpêtrière Charles Foix, 75013, Paris, France
| | - Bruno-Pierre Dubé
- Département de médecine, service de pneumologie, hôpital Hôtel-Dieu du Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada.,Centre de Recherche du Centre Hospitalier de l'Université de Montréal - Carrefour de l'Innovation et de l'Évaluation en santé, Montreal, QC, Canada
| | - Thomas Similowski
- Service de Pneumologie, Médecine intensive - Réanimation (Département "R3S"), AP-HP, Sorbonne Université, Groupe Hospitalier Universitaire Pitié-Salpêtrière Charles Foix, 75013, Paris, France.,UMRS1158 Neurophysiologie respiratoire expérimentale et clinique, Sorbonne Université, Paris, France
| | - Alexandre Demoule
- Service de Pneumologie, Médecine intensive - Réanimation (Département "R3S"), AP-HP, Sorbonne Université, Groupe Hospitalier Universitaire Pitié-Salpêtrière Charles Foix, 75013, Paris, France.,UMRS1158 Neurophysiologie respiratoire expérimentale et clinique, Sorbonne Université, Paris, France
| | - Martin Dres
- Service de Pneumologie, Médecine intensive - Réanimation (Département "R3S"), AP-HP, Sorbonne Université, Groupe Hospitalier Universitaire Pitié-Salpêtrière Charles Foix, 75013, Paris, France. .,UMRS1158 Neurophysiologie respiratoire expérimentale et clinique, Sorbonne Université, Paris, France.
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355
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Itagaki T, Nakanishi N, Takashima T, Ueno Y, Tane N, Tsunano Y, Nunomura T, Oto J. Effect of controlled ventilation during assist-control ventilation on diaphragm thickness : a post hoc analysis of an observational study. THE JOURNAL OF MEDICAL INVESTIGATION 2020; 67:332-337. [PMID: 33148911 DOI: 10.2152/jmi.67.332] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Background : Since diaphragm passivity induces oxidative stress that leads to rapid atrophy of diaphragm, we investigated the effect of controlled ventilation on diaphragm thickness during assist-control ventilation (ACV). Methods : Previously, we measured end-expiratory diaphragm thickness (Tdiee) of patients mechanically ventilated for more than 48 hours on days 1, 3, 5 and 7 after the start of ventilation. We retrospectively investigated the proportion of controlled ventilation during the initial 48-hour ACV (CV48%). Patients were classified according to CV48% : Low group, less than 25% ; High group, higher than 25%. Results : Of 56 patients under pressure-control ACV, Tdiee increased more than 10% in 6 patients (11%), unchanged in 8 patients (14%) and decreased more than 10% in 42 patients (75%). During the first week of ventilation, Tdiee decreased in both groups : Low (difference, -7.4% ; 95% confidence interval [CI], -10.1% to -4.6% ; p < 0.001) and High group (difference, -5.2% ; 95% CI, -8.5% to -2.0% ; p = 0.049). Maximum Tdiee variation from baseline did not differ between Low (-15.8% ; interquartile range [IQR], -22.3 to -1.5) and High group (-16.7% ; IQR, -22.6 to -11.1, p = 0.676). Conclusions : During ACV, maximum variation in Tdiee was not associated with proportion of controlled ventilation higher than 25%. J. Med. Invest. 67 : 332-337, August, 2020.
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Affiliation(s)
- Taiga Itagaki
- Department of Emergency and Critical Care Medicine, Tokushima University Graduate School, Tokushima, Japan
| | - Nobuto Nakanishi
- Department of Emergency and Critical Care Medicine, Tokushima University Graduate School, Tokushima, Japan
| | - Takuya Takashima
- Department of Emergency and Critical Care Medicine, Tokushima University Hospital, Tokushima, Japan
| | - Yoshitoyo Ueno
- Department of Emergency and Critical Care Medicine, Tokushima University Hospital, Tokushima, Japan
| | - Natsuki Tane
- Department of Emergency and Disaster Medicine, Tokushima University Hospital, Tokushima, Japan
| | - Yumiko Tsunano
- Department of Emergency and Critical Care Medicine, Tokushima University Graduate School, Tokushima, Japan
| | - Toshiyuki Nunomura
- Division of Critical Care Center, Kochi Red Cross Hospital, Kochi, Japan
| | - Jun Oto
- Department of Emergency and Disaster Medicine, Tokushima University Hospital, Tokushima, Japan
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356
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Vaporidi K, Akoumianaki E, Telias I, Goligher EC, Brochard L, Georgopoulos D. Respiratory Drive in Critically Ill Patients. Pathophysiology and Clinical Implications. Am J Respir Crit Care Med 2020; 201:20-32. [DOI: 10.1164/rccm.201903-0596so] [Citation(s) in RCA: 97] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Affiliation(s)
- Katerina Vaporidi
- Department of Intensive Care Medicine, University Hospital of Heraklion, Medical School University of Crete, Heraklion, Greece
| | - Evangelia Akoumianaki
- Department of Intensive Care Medicine, University Hospital of Heraklion, Medical School University of Crete, Heraklion, Greece
| | - Irene Telias
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
- Keenan Research Center and Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Ewan C. Goligher
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, University Health Network, Toronto, Ontario, Canada; and
- Toronto General Hospital Research Institute, Toronto, Ontario, Canada
| | - Laurent Brochard
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
- Keenan Research Center and Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Dimitris Georgopoulos
- Department of Intensive Care Medicine, University Hospital of Heraklion, Medical School University of Crete, Heraklion, Greece
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357
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Williams E, Dassios T, Arnold K, Hickey A, Greenough A. Prolonged ventilation and postnatal growth of preterm infants. J Perinat Med 2019; 48:82-86. [PMID: 31714891 DOI: 10.1515/jpm-2019-0278] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 10/10/2019] [Indexed: 01/09/2023]
Abstract
Background Extremely premature infants often need invasive respiratory support from birth, but have low nutritional reserves and high metabolic demands. Our aim was to determine if there was a relationship between prolonged ventilation and reduced postnatal growth in such infants. Methods A retrospective, observational study was undertaken. Data from infants born at less than 28 weeks of gestational age and ventilated for 7 days or more were collected and analysed including gestational age, gender, birth and discharge weight, birth and discharge head circumference, days of invasive mechanical ventilation and use of postnatal corticosteroids. The duration of invasive mechanical ventilation and the differences in weight (ΔWz) and head circumference (ΔHz) z-score from birth to discharge were calculated. Results Fifty-five infants were studied with a median [interquartile range (IQR)] gestational age at birth of 25.3 (24.3-26.7) weeks and birth weight of 0.73 (0.65-0.87) kg. The median duration of mechanical ventilation was 45 (33-68) days. Both ΔWz and ΔHz were significantly negatively correlated to the number of invasive mechanical ventilation days (P = 0.01 and P = 0.03, respectively), but not to the use of postnatal corticosteroids. Conclusion Poor postnatal growth is significantly negatively associated with a longer duration of mechanical ventilation in extremely prematurely born infants.
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Affiliation(s)
- Emma Williams
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Theodore Dassios
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK.,Neonatal Intensive Care Centre, King's College Hospital NHS Foundation Trust, London, UK.,The Asthma UK Centre for Allergic Mechanisms in Asthma, King's College London, London, UK
| | - Kate Arnold
- Paediatric Dietetic Department, King's College Hospital NHS Foundation Trust, London, UK
| | - Ann Hickey
- Neonatal Intensive Care Centre, King's College Hospital NHS Foundation Trust, London, UK
| | - Anne Greenough
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK.,The Asthma UK Centre for Allergic Mechanisms in Asthma, King's College London, London, UK.,NIHR Biomedical Centre at Guy's and St Thomas NHS Foundation Trust and King's College London, London, UK, Tel.: +0203 3299 3037, Fax: +0203 3299 8284
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358
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Nakanishi N, Oto J, Ueno Y, Nakataki E, Itagaki T, Nishimura M. Change in diaphragm and intercostal muscle thickness in mechanically ventilated patients: a prospective observational ultrasonography study. J Intensive Care 2019; 7:56. [PMID: 31827804 PMCID: PMC6886193 DOI: 10.1186/s40560-019-0410-4] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 10/17/2019] [Indexed: 11/15/2022] Open
Abstract
Background Diaphragm atrophy is observed in mechanically ventilated patients. However, the atrophy is not investigated in other respiratory muscles. Therefore, we conducted a two-center prospective observational study to evaluate changes in diaphragm and intercostal muscle thickness in mechanically ventilated patients. Methods Consecutive adult patients who were expected to be mechanically ventilated longer than 48 h in the ICU were enrolled. Diaphragm and intercostal muscle thickness were measured on days 1, 3, 5, and 7 with ultrasonography. The primary outcome was the direction of change in muscle thickness, and the secondary outcomes were the relationship of changes in muscle thickness with patient characteristics. Results Eighty patients (54 males and 26 females; mean age, 68 ± 14 years) were enrolled. Diaphragm muscle thickness decreased, increased, and remained unchanged in 50 (63%), 15 (19%), and 15 (19%) patients, respectively. Intercostal muscle thickness decreased, increased, and remained unchanged in 48 (60%), 15 (19%), and 17 (21%) patients, respectively. Decreased diaphragm or intercostal muscle thickness was associated with prolonged mechanical ventilation (median difference (MD), 3 days; 95% CI (confidence interval), 1–7 and MD, 3 days; 95% CI, 1–7, respectively) and length of ICU stay (MD, 3 days; 95% CI, 1–7 and MD, 3 days; 95% CI, 1–7, respectively) compared with the unchanged group. After adjusting for sex, age, and APACHE II score, they were still associated with prolonged mechanical ventilation (hazard ratio (HR), 4.19; 95% CI, 2.14–7.93 and HR, 2.87; 95% CI, 1.53–5.21, respectively) and length of ICU stay (HR, 3.44; 95% CI, 1.77–6.45 and HR, 2.58; 95% CI, 1.39–4.63, respectively) compared with the unchanged group. Conclusions Decreased diaphragm and intercostal muscle thickness were frequently seen in patients under mechanical ventilation. They were associated with prolonged mechanical ventilation and length of ICU stay. Trial registration UMIN000031316. Registered on 15 February 2018
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Affiliation(s)
- Nobuto Nakanishi
- 1Emergency and Critical Care Medicine, Tokushima University Hospital, 2-50-1 Kuramoto, Tokushima, 770-8503 Japan
| | - Jun Oto
- 1Emergency and Critical Care Medicine, Tokushima University Hospital, 2-50-1 Kuramoto, Tokushima, 770-8503 Japan
| | - Yoshitoyo Ueno
- 1Emergency and Critical Care Medicine, Tokushima University Hospital, 2-50-1 Kuramoto, Tokushima, 770-8503 Japan
| | - Emiko Nakataki
- 2Tokushima Prefectural Central Hospital, 1-10-3 Kuramoto, Tokushima, 770-8539 Japan
| | - Taiga Itagaki
- 1Emergency and Critical Care Medicine, Tokushima University Hospital, 2-50-1 Kuramoto, Tokushima, 770-8503 Japan
| | - Masaji Nishimura
- 2Tokushima Prefectural Central Hospital, 1-10-3 Kuramoto, Tokushima, 770-8539 Japan
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359
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Li SP, Zhou XL, Zhao Y. Sedation with midazolam worsens the diaphragm function than dexmedetomidine and propofol during mechanical ventilation in rats. Biomed Pharmacother 2019; 121:109405. [PMID: 31810122 DOI: 10.1016/j.biopha.2019.109405] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 08/25/2019] [Accepted: 08/28/2019] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Mechanical ventilation (MV) is identified as an independent contributor to diaphragmatic atrophy and contractile dysfunction. Appropriate sedation is also essential during MV, and anesthetics may have direct adverse effects on the diaphragm. However, there is a lack of research into the effects of different anesthetics on diaphragm function during MV. OBJECTIVES In the present study, we aim to examine the effect of midazolam, dexmedetomidine, and propofol on diaphragm function during MV. DESIGN Animal study. SETTING University research laboratory. SUBJECTS Male Wistar rats. INTERVENTIONS Animals were experienced 12 h of MV or spontaneous breathing (SB) with continuous anesthetics infusion. Diaphragm contractile properties, cross-sectional areas, microcirculation, oxidative stress, and proteolysis were examined. MEASUREMENTS AND MAIN RESULTS Diaphragmatic specific force was markedly reduced in the midazolam group compared with the dexmedetomidine (-60.4 ± 3.01%, p < 0.001) and propofol group (-58.3 ± 2.60%, p < 0.001) after MV. MV sedated with midazolam induced more atrophy of type II fibers compared with dexmedetomidine (-21.8 ± 2.11%, p = 0.0001) and propofol (-8.2 ± 1.53%, p = 0.003). No significant differences of these indices were found in the midazolam, dexmedetomidine, and propofol groups under SB condition (all p > 0.05, respectively). Twelve hours of MV resulted in a time dependent reduction in diaphragmatic functional capillary density (PB -25.1%, p = 0.0001; MZ -21.6%, p = 0.0003; DD -15.2%, p = 0.022; PP -24.8%, p = 0.0001, respectively), which did not occur in the gastrocnemius muscle. The diaphragmatic lipid peroxidation adducts 4-HNE and HIF-1α levels were significantly lower in dexmedetomidine group and propofol group compared to midazolam group (p < 0.05, respectively). Meanwhile, the catalase and SOD levels were also relatively lower (p < 0.05, respectively) in midazolam group compared to dexmedetomidine group and propofol group. CONCLUSIONS Twelve hours of mechanical ventilation during midazolam sedation led to a more severe diaphragm dysfunction than dexmedetomidine and propofol, possibly caused by its relative weaker antioxidant capacity.
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Affiliation(s)
- Shao-Ping Li
- 169 Donghu Road, Emergency Center, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, 430071, China
| | - Xian-Long Zhou
- 169 Donghu Road, Emergency Center, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, 430071, China
| | - Yan Zhao
- 169 Donghu Road, Emergency Center, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, 430071, China.
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360
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Dres M, Jung B, Molinari N, Manna F, Dubé BP, Chanques G, Similowski T, Jaber S, Demoule A. Respective contribution of intensive care unit-acquired limb muscle and severe diaphragm weakness on weaning outcome and mortality: a post hoc analysis of two cohorts. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:370. [PMID: 31752937 PMCID: PMC6873450 DOI: 10.1186/s13054-019-2650-z] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/04/2019] [Accepted: 10/16/2019] [Indexed: 01/16/2023]
Abstract
Background Intensive care unit (ICU)-acquired weakness (ICU-AW) and ICU-acquired diaphragm dysfunction (ICU-DD) occur frequently in mechanically ventilated (MV) patients. It is unknown whether they have different risk factors and different impacts on outcome. This study was designed to (1) describe the respective risk factors associated with ICU-AW and severe ICU-DD and (2) evaluate the respective impact of ICU-AW and severe ICU-DD on outcome. Methods Post hoc analysis of two prospective cohort studies conducted in two ICUs. In patients mechanically ventilated for at least 24 h undergoing a first spontaneous breathing trial, severe ICU-DD was defined as diaphragm twitch pressure < 7 cmH2O and ICU-AW was defined as Medical Research Council Score < 48. Results One hundred sixteen patients were assessed. Factors independently associated with severe ICU-DD were age, longer duration of MV, and exposure to sufentanil, and those factors associated with ICU-AW were longer duration of MV and exposure to norepinephrine. Severe ICU-DD (OR 3.56, p = 0.008), but not ICU-AW, was independently associated with weaning failure (59%). ICU-AW (OR 4.30, p = 0.033), but not severe ICU-DD, was associated with ICU mortality. Weaning failure and mortality rate were higher in patients with both severe ICU-DD and ICU-AW (86% and 39%, respectively) than in patients with either severe ICU-DD (64% and 0%) or ICU-AW (63% and 13%). Conclusion Severe ICU-DD and ICU-AW have different risk factors and different impacts on weaning failure and mortality. The impact of the combination of ICU-DD and ICU-AW is more pronounced than their individual impact.
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Affiliation(s)
- Martin Dres
- AP-HP, Sorbonne Université, Hôpital Pitié-Salpêtrière, Service de Pneumologie, Médecine intensive - Réanimation (Département "R3S"), F-75013, Paris, France.,AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Intensive Care Unit and Respiratory Division (Département "R3S"), F-75013, Paris, France
| | - Boris Jung
- Montpellier School of Medicine, University of Montpellier, INSERM U1046, CNRS UMR 9214, Montpellier, France.,Medical Intensive Care Unit, Lapeyronie University Hospital, Montpellier, France
| | - Nicolas Molinari
- Department of Statistics, CHU Montpellier, IMAG, CNRS, Univ Montpellier, Montpellier, France
| | - Federico Manna
- Department of Statistics, CHU Montpellier, IMAG, CNRS, Univ Montpellier, Montpellier, France
| | - Bruno-Pierre Dubé
- AP-HP, Sorbonne Université, Hôpital Pitié-Salpêtrière, Service de Pneumologie, Médecine intensive - Réanimation (Département "R3S"), F-75013, Paris, France.,AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Intensive Care Unit and Respiratory Division (Département "R3S"), F-75013, Paris, France
| | - Gerald Chanques
- Montpellier School of Medicine, University of Montpellier, INSERM U1046, CNRS UMR 9214, Montpellier, France.,Intensive Care and Anesthesiology Department, Saint Eloi Hospital, Montpellier, France
| | - Thomas Similowski
- AP-HP, Sorbonne Université, Hôpital Pitié-Salpêtrière, Service de Pneumologie, Médecine intensive - Réanimation (Département "R3S"), F-75013, Paris, France.,AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Intensive Care Unit and Respiratory Division (Département "R3S"), F-75013, Paris, France
| | - Samir Jaber
- Montpellier School of Medicine, University of Montpellier, INSERM U1046, CNRS UMR 9214, Montpellier, France.,Intensive Care and Anesthesiology Department, Saint Eloi Hospital, Montpellier, France
| | - Alexandre Demoule
- AP-HP, Sorbonne Université, Hôpital Pitié-Salpêtrière, Service de Pneumologie, Médecine intensive - Réanimation (Département "R3S"), F-75013, Paris, France. .,AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Intensive Care Unit and Respiratory Division (Département "R3S"), F-75013, Paris, France. .,Service de Pneumologie, Médecine Intensive et Réanimation, Groupe Hospitalier Pitié-Salpêtrière, 47-83 Boulevard de l'Hôpital, 75651, Paris Cedex 13, France.
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361
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Dres M, Jung B, Molinari N, Manna F, Dubé BP, Chanques G, Similowski T, Jaber S, Demoule A. Respective contribution of intensive care unit-acquired limb muscle and severe diaphragm weakness on weaning outcome and mortality: a post hoc analysis of two cohorts. CRITICAL CARE (LONDON, ENGLAND) 2019. [PMID: 31752937 DOI: 10.1186/s13054-019-2650-z].] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Intensive care unit (ICU)-acquired weakness (ICU-AW) and ICU-acquired diaphragm dysfunction (ICU-DD) occur frequently in mechanically ventilated (MV) patients. It is unknown whether they have different risk factors and different impacts on outcome. This study was designed to (1) describe the respective risk factors associated with ICU-AW and severe ICU-DD and (2) evaluate the respective impact of ICU-AW and severe ICU-DD on outcome. METHODS Post hoc analysis of two prospective cohort studies conducted in two ICUs. In patients mechanically ventilated for at least 24 h undergoing a first spontaneous breathing trial, severe ICU-DD was defined as diaphragm twitch pressure < 7 cmH2O and ICU-AW was defined as Medical Research Council Score < 48. RESULTS One hundred sixteen patients were assessed. Factors independently associated with severe ICU-DD were age, longer duration of MV, and exposure to sufentanil, and those factors associated with ICU-AW were longer duration of MV and exposure to norepinephrine. Severe ICU-DD (OR 3.56, p = 0.008), but not ICU-AW, was independently associated with weaning failure (59%). ICU-AW (OR 4.30, p = 0.033), but not severe ICU-DD, was associated with ICU mortality. Weaning failure and mortality rate were higher in patients with both severe ICU-DD and ICU-AW (86% and 39%, respectively) than in patients with either severe ICU-DD (64% and 0%) or ICU-AW (63% and 13%). CONCLUSION Severe ICU-DD and ICU-AW have different risk factors and different impacts on weaning failure and mortality. The impact of the combination of ICU-DD and ICU-AW is more pronounced than their individual impact.
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Affiliation(s)
- Martin Dres
- AP-HP, Sorbonne Université, Hôpital Pitié-Salpêtrière, Service de Pneumologie, Médecine intensive - Réanimation (Département "R3S"), F-75013, Paris, France.,AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Intensive Care Unit and Respiratory Division (Département "R3S"), F-75013, Paris, France
| | - Boris Jung
- Montpellier School of Medicine, University of Montpellier, INSERM U1046, CNRS UMR 9214, Montpellier, France.,Medical Intensive Care Unit, Lapeyronie University Hospital, Montpellier, France
| | - Nicolas Molinari
- Department of Statistics, CHU Montpellier, IMAG, CNRS, Univ Montpellier, Montpellier, France
| | - Federico Manna
- Department of Statistics, CHU Montpellier, IMAG, CNRS, Univ Montpellier, Montpellier, France
| | - Bruno-Pierre Dubé
- AP-HP, Sorbonne Université, Hôpital Pitié-Salpêtrière, Service de Pneumologie, Médecine intensive - Réanimation (Département "R3S"), F-75013, Paris, France.,AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Intensive Care Unit and Respiratory Division (Département "R3S"), F-75013, Paris, France
| | - Gerald Chanques
- Montpellier School of Medicine, University of Montpellier, INSERM U1046, CNRS UMR 9214, Montpellier, France.,Intensive Care and Anesthesiology Department, Saint Eloi Hospital, Montpellier, France
| | - Thomas Similowski
- AP-HP, Sorbonne Université, Hôpital Pitié-Salpêtrière, Service de Pneumologie, Médecine intensive - Réanimation (Département "R3S"), F-75013, Paris, France.,AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Intensive Care Unit and Respiratory Division (Département "R3S"), F-75013, Paris, France
| | - Samir Jaber
- Montpellier School of Medicine, University of Montpellier, INSERM U1046, CNRS UMR 9214, Montpellier, France.,Intensive Care and Anesthesiology Department, Saint Eloi Hospital, Montpellier, France
| | - Alexandre Demoule
- AP-HP, Sorbonne Université, Hôpital Pitié-Salpêtrière, Service de Pneumologie, Médecine intensive - Réanimation (Département "R3S"), F-75013, Paris, France. .,AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Intensive Care Unit and Respiratory Division (Département "R3S"), F-75013, Paris, France. .,Service de Pneumologie, Médecine Intensive et Réanimation, Groupe Hospitalier Pitié-Salpêtrière, 47-83 Boulevard de l'Hôpital, 75651, Paris Cedex 13, France.
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362
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Dres M, Jung B, Molinari N, Manna F, Dubé BP, Chanques G, Similowski T, Jaber S, Demoule A. Respective contribution of intensive care unit-acquired limb muscle and severe diaphragm weakness on weaning outcome and mortality: a post hoc analysis of two cohorts. CRITICAL CARE (LONDON, ENGLAND) 2019. [PMID: 31752937 DOI: 10.1186/s13054-019-2650-z]] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Intensive care unit (ICU)-acquired weakness (ICU-AW) and ICU-acquired diaphragm dysfunction (ICU-DD) occur frequently in mechanically ventilated (MV) patients. It is unknown whether they have different risk factors and different impacts on outcome. This study was designed to (1) describe the respective risk factors associated with ICU-AW and severe ICU-DD and (2) evaluate the respective impact of ICU-AW and severe ICU-DD on outcome. METHODS Post hoc analysis of two prospective cohort studies conducted in two ICUs. In patients mechanically ventilated for at least 24 h undergoing a first spontaneous breathing trial, severe ICU-DD was defined as diaphragm twitch pressure < 7 cmH2O and ICU-AW was defined as Medical Research Council Score < 48. RESULTS One hundred sixteen patients were assessed. Factors independently associated with severe ICU-DD were age, longer duration of MV, and exposure to sufentanil, and those factors associated with ICU-AW were longer duration of MV and exposure to norepinephrine. Severe ICU-DD (OR 3.56, p = 0.008), but not ICU-AW, was independently associated with weaning failure (59%). ICU-AW (OR 4.30, p = 0.033), but not severe ICU-DD, was associated with ICU mortality. Weaning failure and mortality rate were higher in patients with both severe ICU-DD and ICU-AW (86% and 39%, respectively) than in patients with either severe ICU-DD (64% and 0%) or ICU-AW (63% and 13%). CONCLUSION Severe ICU-DD and ICU-AW have different risk factors and different impacts on weaning failure and mortality. The impact of the combination of ICU-DD and ICU-AW is more pronounced than their individual impact.
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Affiliation(s)
- Martin Dres
- AP-HP, Sorbonne Université, Hôpital Pitié-Salpêtrière, Service de Pneumologie, Médecine intensive - Réanimation (Département "R3S"), F-75013, Paris, France.,AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Intensive Care Unit and Respiratory Division (Département "R3S"), F-75013, Paris, France
| | - Boris Jung
- Montpellier School of Medicine, University of Montpellier, INSERM U1046, CNRS UMR 9214, Montpellier, France.,Medical Intensive Care Unit, Lapeyronie University Hospital, Montpellier, France
| | - Nicolas Molinari
- Department of Statistics, CHU Montpellier, IMAG, CNRS, Univ Montpellier, Montpellier, France
| | - Federico Manna
- Department of Statistics, CHU Montpellier, IMAG, CNRS, Univ Montpellier, Montpellier, France
| | - Bruno-Pierre Dubé
- AP-HP, Sorbonne Université, Hôpital Pitié-Salpêtrière, Service de Pneumologie, Médecine intensive - Réanimation (Département "R3S"), F-75013, Paris, France.,AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Intensive Care Unit and Respiratory Division (Département "R3S"), F-75013, Paris, France
| | - Gerald Chanques
- Montpellier School of Medicine, University of Montpellier, INSERM U1046, CNRS UMR 9214, Montpellier, France.,Intensive Care and Anesthesiology Department, Saint Eloi Hospital, Montpellier, France
| | - Thomas Similowski
- AP-HP, Sorbonne Université, Hôpital Pitié-Salpêtrière, Service de Pneumologie, Médecine intensive - Réanimation (Département "R3S"), F-75013, Paris, France.,AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Intensive Care Unit and Respiratory Division (Département "R3S"), F-75013, Paris, France
| | - Samir Jaber
- Montpellier School of Medicine, University of Montpellier, INSERM U1046, CNRS UMR 9214, Montpellier, France.,Intensive Care and Anesthesiology Department, Saint Eloi Hospital, Montpellier, France
| | - Alexandre Demoule
- AP-HP, Sorbonne Université, Hôpital Pitié-Salpêtrière, Service de Pneumologie, Médecine intensive - Réanimation (Département "R3S"), F-75013, Paris, France. .,AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Intensive Care Unit and Respiratory Division (Département "R3S"), F-75013, Paris, France. .,Service de Pneumologie, Médecine Intensive et Réanimation, Groupe Hospitalier Pitié-Salpêtrière, 47-83 Boulevard de l'Hôpital, 75651, Paris Cedex 13, France.
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363
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Khemani RG, Hotz JC, Klein MJ, Kwok J, Park C, Lane C, Smith E, Kohler K, Suresh A, Bornstein D, Elkunovich M, Ross PA, Deakers T, Beltramo F, Nelson L, Shah S, Bhalla A, Curley MAQ, Newth CJL. A Phase II randomized controlled trial for lung and diaphragm protective ventilation (Real-time Effort Driven VENTilator management). Contemp Clin Trials 2019; 88:105893. [PMID: 31740425 DOI: 10.1016/j.cct.2019.105893] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 11/05/2019] [Accepted: 11/14/2019] [Indexed: 11/18/2022]
Abstract
Lung Protective Mechanical Ventilation (MV) of critically ill adults and children is lifesaving but it may decrease diaphragm contraction and promote Ventilator Induced Diaphragm Dysfunction (VIDD). An ideal MV strategy would balance lung and diaphragm protection. Building off a Phase I pilot study, we are conducting a Phase II controlled clinical trial that seeks to understand the evolution of VIDD in critically ill children and test whether a novel computer-based approach (Real-time Effort Driven ventilator management (REDvent)) can balance lung and diaphragm protective ventilation to reduce time on MV. REDvent systematically adjusts PEEP, FiO2, inspiratory pressure, tidal volume and rate, and uses real-time measures from esophageal manometry to target normal levels of patient effort of breathing. This trial targets 276 children with pulmonary parenchymal disease. Patients are randomized to REDvent vs. usual care for the acute phase of MV (intubation to first Spontaneous Breathing Trial (SBT)). Patients in either group who fail their first SBT will be randomized to REDvent vs usual care for weaning phase management (interval from first SBT to passing SBT). The primary clinical outcome is length of weaning, with several mechanistic outcomes. Upon completion, this study will provide important information on the pathogenesis and timing of VIDD during MV in children and whether this computerized protocol targeting lung and diaphragm protection can lead to improvement in intermediate clinical outcomes. This will form the basis for a larger, Phase III multi-center study, powered for key clinical outcomes such as 28-day ventilator free days. Clinical Trials Registration: NCT03266016.
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Affiliation(s)
- Robinder G Khemani
- Children's Hospital Los Angeles, Department of Anesthesiology and Critical Care, United States of America; University of Southern California, Keck School of Medicine, Department of Pediatrics, United States of America.
| | - Justin C Hotz
- Children's Hospital Los Angeles, Department of Anesthesiology and Critical Care, United States of America
| | - Margaret J Klein
- Children's Hospital Los Angeles, Department of Anesthesiology and Critical Care, United States of America
| | - Jeni Kwok
- Children's Hospital Los Angeles, Department of Anesthesiology and Critical Care, United States of America
| | - Caron Park
- University of Southern California, Keck School of Medicine, Department of Preventative Medicine, United States of America
| | - Christianne Lane
- University of Southern California, Keck School of Medicine, Department of Preventative Medicine, United States of America
| | - Erin Smith
- Children's Hospital Los Angeles, Department of Anesthesiology and Critical Care, United States of America
| | - Kristen Kohler
- Children's Hospital Los Angeles, Department of Anesthesiology and Critical Care, United States of America
| | - Anil Suresh
- Children's Hospital Los Angeles, Department of Anesthesiology and Critical Care, United States of America
| | - Dinnel Bornstein
- Children's Hospital Los Angeles, Department of Anesthesiology and Critical Care, United States of America
| | - Marsha Elkunovich
- University of Southern California, Keck School of Medicine, Department of Pediatrics, United States of America; Children's Hospital of Los Angeles, Department of Emergency Medicine, United States of America
| | - Patrick A Ross
- Children's Hospital Los Angeles, Department of Anesthesiology and Critical Care, United States of America; University of Southern California, Keck School of Medicine, Department of Pediatrics, United States of America
| | - Timothy Deakers
- Children's Hospital Los Angeles, Department of Anesthesiology and Critical Care, United States of America; University of Southern California, Keck School of Medicine, Department of Pediatrics, United States of America
| | - Fernando Beltramo
- Children's Hospital Los Angeles, Department of Anesthesiology and Critical Care, United States of America; University of Southern California, Keck School of Medicine, Department of Pediatrics, United States of America
| | - Lara Nelson
- Children's Hospital Los Angeles, Department of Anesthesiology and Critical Care, United States of America; University of Southern California, Keck School of Medicine, Department of Pediatrics, United States of America
| | - Shilpa Shah
- Children's Hospital Los Angeles, Department of Anesthesiology and Critical Care, United States of America; University of Southern California, Keck School of Medicine, Department of Pediatrics, United States of America
| | - Anoopindar Bhalla
- Children's Hospital Los Angeles, Department of Anesthesiology and Critical Care, United States of America; University of Southern California, Keck School of Medicine, Department of Pediatrics, United States of America
| | - Martha A Q Curley
- Children's Hospital Philadelphia, University of Pennsylvania, United States of America
| | - Christopher J L Newth
- Children's Hospital Los Angeles, Department of Anesthesiology and Critical Care, United States of America; University of Southern California, Keck School of Medicine, Department of Pediatrics, United States of America
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364
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Hemorrhagic Shock Sensitized the Diaphragm to Ventilator-Induced Dysfunction through the Activation of IL-6/JAK/STAT Signaling-Mediated Autophagy in Rats. Mediators Inflamm 2019; 2019:3738409. [PMID: 31814800 PMCID: PMC6878811 DOI: 10.1155/2019/3738409] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Accepted: 09/03/2019] [Indexed: 01/15/2023] Open
Abstract
Mechanical ventilation (MV) is a major life support technique for the management of trauma-associated hemorrhagic shock (HS). Ventilator-induced diaphragm dysfunction (VIDD), one of the most common complications of MV, has been well demonstrated in animal and human studies. However, few data are available concerning the effects of MV on diaphragm function in HS victims. In the present study, we found diaphragm muscle atrophy and weakness in HS but not in healthy animals after 4 hours of MV. The inhibition of autophagy resulted in reduced muscle fiber atrophy and improved forces. In addition, we observed diaphragmatic interleukin- (IL-) 6 overexpression and activation of its downstream signaling JAK/STAT in HS animals after MV, and either the neutralization of IL-6 or the inhibition of the JAK/STAT pathway attenuated autophagy, diaphragm atrophy, and weakness. Importantly, treatment with nonselective antioxidant exerted no protective effects against VIDD in HS animals. In addition, in vitro study showed that exogenous IL-6 was able to induce activation of JAK/STAT signaling and to increase autophagy in C2C12 cells. Moreover, the inhibition of JAK/STAT signaling abolished IL-6-induced cell autophagy. Together, our results suggested that HS sensitized the diaphragm to ventilator-induced atrophy and weakness through the activation of IL-6/JAK/STAT signaling-mediated autophagy in rats.
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365
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Spontaneous Breathing in Early Acute Respiratory Distress Syndrome: Insights From the Large Observational Study to UNderstand the Global Impact of Severe Acute Respiratory FailurE Study. Crit Care Med 2019; 47:229-238. [PMID: 30379668 PMCID: PMC6336491 DOI: 10.1097/ccm.0000000000003519] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Supplemental Digital Content is available in the text. Objectives: To describe the characteristics and outcomes of patients with acute respiratory distress syndrome with or without spontaneous breathing and to investigate whether the effects of spontaneous breathing on outcome depend on acute respiratory distress syndrome severity. Design: Planned secondary analysis of a prospective, observational, multicentre cohort study. Setting: International sample of 459 ICUs from 50 countries. Patients: Patients with acute respiratory distress syndrome and at least 2 days of invasive mechanical ventilation and available data for the mode of mechanical ventilation and respiratory rate for the 2 first days. Interventions: Analysis of patients with and without spontaneous breathing, defined by the mode of mechanical ventilation and by actual respiratory rate compared with set respiratory rate during the first 48 hours of mechanical ventilation. Measurements and Main Results: Spontaneous breathing was present in 67% of patients with mild acute respiratory distress syndrome, 58% of patients with moderate acute respiratory distress syndrome, and 46% of patients with severe acute respiratory distress syndrome. Patients with spontaneous breathing were older and had lower acute respiratory distress syndrome severity, Sequential Organ Failure Assessment scores, ICU and hospital mortality, and were less likely to be diagnosed with acute respiratory distress syndrome by clinicians. In adjusted analysis, spontaneous breathing during the first 2 days was not associated with an effect on ICU or hospital mortality (33% vs 37%; odds ratio, 1.18 [0.92–1.51]; p = 0.19 and 37% vs 41%; odds ratio, 1.18 [0.93–1.50]; p = 0.196, respectively ). Spontaneous breathing was associated with increased ventilator-free days (13 [0–22] vs 8 [0–20]; p = 0.014) and shorter duration of ICU stay (11 [6–20] vs 12 [7–22]; p = 0.04). Conclusions: Spontaneous breathing is common in patients with acute respiratory distress syndrome during the first 48 hours of mechanical ventilation. Spontaneous breathing is not associated with worse outcomes and may hasten liberation from the ventilator and from ICU. Although these results support the use of spontaneous breathing in patients with acute respiratory distress syndrome independent of acute respiratory distress syndrome severity, the use of controlled ventilation indicates a bias toward use in patients with higher disease severity. In addition, because the lack of reliable data on inspiratory effort in our study, prospective studies incorporating the magnitude of inspiratory effort and adjusting for all potential severity confounders are required.
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366
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Akoumianaki E, Vaporidi K, Georgopoulos D. The Injurious Effects of Elevated or Nonelevated Respiratory Rate during Mechanical Ventilation. Am J Respir Crit Care Med 2019; 199:149-157. [PMID: 30199652 DOI: 10.1164/rccm.201804-0726ci] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Respiratory rate is one of the key variables that is set and monitored during mechanical ventilation. As part of increasing efforts to optimize mechanical ventilation, it is prudent to expand understanding of the potential harmful effects of not only volume and pressures but also respiratory rate. The mechanisms by which respiratory rate may become injurious during mechanical ventilation can be distinguished in two broad categories. In the first, well-recognized category, concerning both controlled and assisted ventilation, the respiratory rate per se may promote ventilator-induced lung injury, dynamic hyperinflation, ineffective efforts, and respiratory alkalosis. It may also be misinterpreted as distress delaying the weaning process. In the second category, which concerns only assisted ventilation, the respiratory rate may induce injury in a less apparent way by remaining relatively quiescent while being challenged by chemical feedback. By responding minimally to chemical feedback, respiratory rate leaves the control of V. e almost exclusively to inspiratory effort. In such cases, when assist is high, weak inspiratory efforts promote ineffective triggering, periodic breathing, and diaphragmatic atrophy. Conversely, when assist is low, diaphragmatic efforts are intense and increase the risk for respiratory distress, asynchronies, ventilator-induced lung injury, diaphragmatic injury, and cardiovascular complications. This review thoroughly presents the multiple mechanisms by which respiratory rate may induce injury during mechanical ventilation, drawing the attention of critical care physicians to the potential injurious effects of respiratory rate insensitivity to chemical feedback during assisted ventilation.
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Affiliation(s)
- Evangelia Akoumianaki
- 1 Intensive Care Medicine Department, University Hospital of Heraklion, Medical School, University of Crete, Heraklion, Crete, Greece
| | - Katerina Vaporidi
- 1 Intensive Care Medicine Department, University Hospital of Heraklion, Medical School, University of Crete, Heraklion, Crete, Greece
| | - Dimitris Georgopoulos
- 1 Intensive Care Medicine Department, University Hospital of Heraklion, Medical School, University of Crete, Heraklion, Crete, Greece
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367
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Bertoni M, Telias I, Urner M, Long M, Del Sorbo L, Fan E, Sinderby C, Beck J, Liu L, Qiu H, Wong J, Slutsky AS, Ferguson ND, Brochard LJ, Goligher EC. A novel non-invasive method to detect excessively high respiratory effort and dynamic transpulmonary driving pressure during mechanical ventilation. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:346. [PMID: 31694692 PMCID: PMC6836358 DOI: 10.1186/s13054-019-2617-0] [Citation(s) in RCA: 126] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Accepted: 09/20/2019] [Indexed: 01/12/2023]
Abstract
Background Excessive respiratory muscle effort during mechanical ventilation may cause patient self-inflicted lung injury and load-induced diaphragm myotrauma, but there are no non-invasive methods to reliably detect elevated transpulmonary driving pressure and elevated respiratory muscle effort during assisted ventilation. We hypothesized that the swing in airway pressure generated by respiratory muscle effort under assisted ventilation when the airway is briefly occluded (ΔPocc) could be used as a highly feasible non-invasive technique to screen for these conditions. Methods Respiratory muscle pressure (Pmus), dynamic transpulmonary driving pressure (ΔPL,dyn, the difference between peak and end-expiratory transpulmonary pressure), and ΔPocc were measured daily in mechanically ventilated patients in two ICUs in Toronto, Canada. A conversion factor to predict ΔPL,dyn and Pmus from ΔPocc was derived and validated using cross-validation. External validity was assessed in an independent cohort (Nanjing, China). Results Fifty-two daily recordings were collected in 16 patients. In this sample, Pmus and ΔPL were frequently excessively high: Pmus exceeded 10 cm H2O on 84% of study days and ΔPL,dyn exceeded 15 cm H2O on 53% of study days. ΔPocc measurements accurately detected Pmus > 10 cm H2O (AUROC 0.92, 95% CI 0.83–0.97) and ΔPL,dyn > 15 cm H2O (AUROC 0.93, 95% CI 0.86–0.99). In the external validation cohort (n = 12), estimating Pmus and ΔPL,dyn from ΔPocc measurements detected excessively high Pmus and ΔPL,dyn with similar accuracy (AUROC ≥ 0.94). Conclusions Measuring ΔPocc enables accurate non-invasive detection of elevated respiratory muscle pressure and transpulmonary driving pressure. Excessive respiratory effort and transpulmonary driving pressure may be frequent in spontaneously breathing ventilated patients.
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Affiliation(s)
- Michele Bertoni
- Department of Anesthesia, Critical Care and Emergency, Spedali Civili di Brescia, University of Brescia, UNIBS, Brescia, Italy.,Department of Medical and Surgical Specialities, Radiological Sciences and Public Health, University of Brescia, UNIBS, Brescia, Italy
| | - Irene Telias
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.,Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
| | - Martin Urner
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.,Division of Respirology, Department of Medicine, University Health Network and University of Toronto, Toronto, Canada
| | - Michael Long
- Respiratory Therapy, University Health Network, Toronto, Canada
| | - Lorenzo Del Sorbo
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.,Division of Respirology, Department of Medicine, University Health Network and University of Toronto, Toronto, Canada
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.,Division of Respirology, Department of Medicine, University Health Network and University of Toronto, Toronto, Canada.,Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, Canada
| | - Christer Sinderby
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.,Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
| | - Jennifer Beck
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.,Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
| | - Ling Liu
- Department of Critical Care Medicine, Zhongda Hospital, Southeast University, Nanjing, China
| | - Haibo Qiu
- Department of Critical Care Medicine, Zhongda Hospital, Southeast University, Nanjing, China
| | - Jenna Wong
- Division of Respirology, Department of Medicine, University Health Network and University of Toronto, Toronto, Canada
| | - Arthur S Slutsky
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.,Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
| | - Niall D Ferguson
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.,Division of Respirology, Department of Medicine, University Health Network and University of Toronto, Toronto, Canada.,Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, Canada.,Department of Physiology, University of Toronto, Toronto, Canada.,Toronto General Hospital Research Institute, Toronto, Canada
| | - Laurent J Brochard
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.,Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
| | - Ewan C Goligher
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada. .,Division of Respirology, Department of Medicine, University Health Network and University of Toronto, Toronto, Canada. .,Toronto General Hospital Research Institute, Toronto, Canada. .,Toronto General Hospital, 585 University Ave., Peter Munk Building, 11th Floor, Room 192, Toronto, ON, M5G 2N2, Canada.
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368
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Roesthuis L, van der Hoeven H, Sinderby C, Frenzel T, Ottenheijm C, Brochard L, Doorduin J, Heunks L. Effects of levosimendan on respiratory muscle function in patients weaning from mechanical ventilation. Intensive Care Med 2019; 45:1372-1381. [PMID: 31576436 PMCID: PMC6773912 DOI: 10.1007/s00134-019-05767-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 08/23/2019] [Indexed: 12/13/2022]
Abstract
PURPOSE Respiratory muscle weakness frequently develops in critically ill patients and is associated with adverse outcome, including difficult weaning from mechanical ventilation. Today, no drug is approved to improve respiratory muscle function in these patients. Previously, we have shown that the calcium sensitizer levosimendan improves calcium sensitivity of human diaphragm muscle fibers in vitro and contractile efficiency of the diaphragm in healthy subjects. The main purpose of this study is to investigate the effects of levosimendan on diaphragm contractile efficiency in mechanically ventilated patients. METHODS In a double-blind randomized placebo-controlled trial, mechanically ventilated patients performed two 30-min continuous positive airway pressure (CPAP) trials with 5-h interval. After the first CPAP trial, study medication (levosimendan 0.2 µg/kg/min continuous infusion or placebo) was administered. During the CPAP trials, electrical activity of the diaphragm (EAdi), transdiaphragmatic pressure (Pdi), and flow were measured. Neuromechanical efficiency (primary outcome parameter) was calculated. RESULTS Thirty-nine patients were included in the study. Neuromechanical efficiency was not different during the CPAP trial after levosimendan administration compared to the CPAP trial before study medication. Tidal volume and minute ventilation were higher after levosimendan administration (11 and 21%, respectively), whereas EAdi and Pdi were higher in both groups in the CPAP trial after study medication compared to the CPAP trial before study medication. CONCLUSIONS Levosimendan does not improve diaphragm contractile efficiency.
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Affiliation(s)
- Lisanne Roesthuis
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Hans van der Hoeven
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Christer Sinderby
- Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
- Institute for Biomedical Engineering and Science Technology (iBEST), Ryerson University and St. Michael's Hospital, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Tim Frenzel
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Coen Ottenheijm
- Department of Physiology, Amsterdam UMC, location VUmc, Amsterdam, The Netherlands
- Department of Cellular and Molecular Medicine, University of Arizona, Tucson, AZ, USA
| | - Laurent Brochard
- Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Jonne Doorduin
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Leo Heunks
- Department of Intensive Care Medicine, Amsterdam UMC, location VUmc, Postbox 7057, 1007 MB, Amsterdam, The Netherlands.
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369
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Beloncle F, Piquilloud L, Olivier PY, Vuillermoz A, Yvin E, Mercat A, Richard JC. Accuracy of P0.1 measurements performed by ICU ventilators: a bench study. Ann Intensive Care 2019; 9:104. [PMID: 31520230 PMCID: PMC6744533 DOI: 10.1186/s13613-019-0576-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Accepted: 09/05/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Occlusion pressure at 100 ms (P0.1), defined as the negative pressure measured 100 ms after the initiation of an inspiratory effort performed against a closed respiratory circuit, has been shown to be well correlated with central respiratory drive and respiratory effort. Automated P0.1 measurement is available on modern ventilators. However, the reliability of this measurement has never been studied. This bench study aimed at assessing the accuracy of P0.1 measurements automatically performed by different ICU ventilators. METHODS Five ventilators set in pressure support mode were tested using a two-chamber test lung model simulating spontaneous breathing. P0.1 automatically displayed on the ventilator screen (P0.1vent) was recorded at three levels of simulated inspiratory effort corresponding to P0.1 of 2.5, 5 and 10 cm H2O measured directly at the test lung and considered as the reference values of P0.1 (P0.1ref). The pressure drop after 100 ms was measured offline on the airway pressure-time curves recorded during the automated P0.1 measurements (P0.1aw). P0.1vent was compared to P0.1ref and to P0.1aw. To assess the potential impact of the circuit length, P0.1 were also measured with circuits of different lengths (P0.1circuit). RESULTS Variations of P0.1vent correlated well with variations of P0.1ref. Overall, P0.1vent underestimated P0.1ref except for the Löwenstein® ventilator at P0.1ref 2.5 cm H2O and for the Getinge group® ventilator at P0.1ref 10 cm H2O. The agreement between P0.1vent and P0.1ref assessed with the Bland-Altman method gave a mean bias of - 1.3 cm H2O (limits of agreement: 1 and - 3.7 cm H2O). Analysis of airway pressure-time and flow-time curves showed that all the tested ventilators except the Getinge group® ventilator performed an occlusion of at least 100 ms to measure P0.1. The agreement between P0.1vent and P0.1aw assessed with the Bland-Altman method gave a mean bias of 0.5 cm H2O (limits of agreement: 2.4 and - 1.4 cm H2O). The circuit's length impacted P0.1 measurements' values. A longer circuit was associated with lower P0.1circuit values. CONCLUSION P0.1vent relative changes are well correlated to P0.1ref changes in all the tested ventilators. Accuracy of absolute values of P0.1vent varies according to the ventilator model. Overall, P0.1vent underestimates P0.1ref. The length of the circuit may partially explain P0.1vent underestimation.
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Affiliation(s)
- François Beloncle
- Medical Intensive Care Unit, University Hospital of Angers, UNIV Angers, 4 rue Larrey, 49933, Angers Cedex 9, France.
| | - Lise Piquilloud
- Medical Intensive Care Unit, University Hospital of Angers, UNIV Angers, 4 rue Larrey, 49933, Angers Cedex 9, France.,Adult Intensive Care and Burn Unit, University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Pierre-Yves Olivier
- Medical Intensive Care Unit, University Hospital of Angers, UNIV Angers, 4 rue Larrey, 49933, Angers Cedex 9, France.,Intensive Care Unit, General Hospital of Le Mans, Le Mans, France
| | - Alice Vuillermoz
- Medical Intensive Care Unit, University Hospital of Angers, UNIV Angers, 4 rue Larrey, 49933, Angers Cedex 9, France
| | - Elise Yvin
- Medical Intensive Care Unit, University Hospital of Angers, UNIV Angers, 4 rue Larrey, 49933, Angers Cedex 9, France
| | - Alain Mercat
- Medical Intensive Care Unit, University Hospital of Angers, UNIV Angers, 4 rue Larrey, 49933, Angers Cedex 9, France
| | - Jean-Christophe Richard
- SAMU74, Emergency Department, General Hospital of Annecy, Annecy, France.,INSERM, UMR 1066, Creteil, France
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370
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de Souza GM, Vianna FSL, Midega TD, Serpa Neto A. Probability of benefit with the use of neuromuscular blockade in patients with acute respiratory distress syndrome. J Thorac Dis 2019; 11:3676-3680. [PMID: 31656637 DOI: 10.21037/jtd.2019.09.26] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
| | | | - Thais Dias Midega
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Ary Serpa Neto
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil.,Department of Intensive Care, Academic Medical Center, Amsterdam, The Netherlands.,Pulmonary Division, Cardio-Pulmonary Department, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, Brazil
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371
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Extracorporeal Carbon Dioxide Removal in the Management of Complex Bilateral Flail Chest Injury. ASAIO J 2019; 65:e75-e77. [DOI: 10.1097/mat.0000000000000942] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
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372
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Vetrugno L, Guadagnin GM, Barbariol F, Langiano N, Zangrillo A, Bove T. Ultrasound Imaging for Diaphragm Dysfunction: A Narrative Literature Review. J Cardiothorac Vasc Anesth 2019; 33:2525-2536. [DOI: 10.1053/j.jvca.2019.01.003] [Citation(s) in RCA: 65] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Indexed: 12/15/2022]
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373
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Dres M, Demoule A. Beyond Ventilator-induced Diaphragm Dysfunction: New Evidence for Critical Illness-associated Diaphragm Weakness. Anesthesiology 2019; 131:462-463. [PMID: 31206375 DOI: 10.1097/aln.0000000000002825] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Martin Dres
- From the Sorbonne University, Experimental and Clinical Neurophysiology, National Institute for Health and Medical Research (INSERM, UMRS-1158; M.D.) the Pneumology and Intensive Care Department, Pitie Salpetriere Hospital, F-75013, (A.D.), Paris, France
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374
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Morais CCA, Koyama Y, Yoshida T, Plens GM, Gomes S, Lima CAS, Ramos OPS, Pereira SM, Kawaguchi N, Yamamoto H, Uchiyama A, Borges JB, Vidal Melo MF, Tucci MR, Amato MBP, Kavanagh BP, Costa ELV, Fujino Y. High Positive End-Expiratory Pressure Renders Spontaneous Effort Noninjurious. Am J Respir Crit Care Med 2019; 197:1285-1296. [PMID: 29323536 DOI: 10.1164/rccm.201706-1244oc] [Citation(s) in RCA: 157] [Impact Index Per Article: 26.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
RATIONALE In acute respiratory distress syndrome (ARDS), atelectatic solid-like lung tissue impairs transmission of negative swings in pleural pressure (Ppl) that result from diaphragmatic contraction. The localization of more negative Ppl proportionally increases dependent lung stretch by drawing gas either from other lung regions (e.g., nondependent lung [pendelluft]) or from the ventilator. Lowering the level of spontaneous effort and/or converting solid-like to fluid-like lung might render spontaneous effort noninjurious. OBJECTIVES To determine whether spontaneous effort increases dependent lung injury, and whether such injury would be reduced by recruiting atelectatic solid-like lung with positive end-expiratory pressure (PEEP). METHODS Established models of severe ARDS (rabbit, pig) were used. Regional histology (rabbit), inflammation (positron emission tomography; pig), regional inspiratory Ppl (intrabronchial balloon manometry), and stretch (electrical impedance tomography; pig) were measured. Respiratory drive was evaluated in 11 patients with ARDS. MEASUREMENTS AND MAIN RESULTS Although injury during muscle paralysis was predominantly in nondependent and middle lung regions at low (vs. high) PEEP, strong inspiratory effort increased injury (indicated by positron emission tomography and histology) in dependent lung. Stronger effort (vs. muscle paralysis) caused local overstretch and greater tidal recruitment in dependent lung, where more negative Ppl was localized and greater stretch was generated. In contrast, high PEEP minimized lung injury by more uniformly distributing negative Ppl, and lowering the magnitude of spontaneous effort (i.e., deflection in esophageal pressure observed in rabbits, pigs, and patients). CONCLUSIONS Strong effort increased dependent lung injury, where higher local lung stress and stretch was generated; effort-dependent lung injury was minimized by high PEEP in severe ARDS, which may offset need for paralysis.
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Affiliation(s)
- Caio C A Morais
- 1 Divisao de Pneumologia, Instituto do Coracao (Incor), Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Yukiko Koyama
- 2 Intensive Care Unit, Osaka University Hospital, Suita, Japan
| | - Takeshi Yoshida
- 2 Intensive Care Unit, Osaka University Hospital, Suita, Japan.,3 Translational Medicine, Departments of Critical Care Medicine and Anesthesia, Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Glauco M Plens
- 1 Divisao de Pneumologia, Instituto do Coracao (Incor), Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Susimeire Gomes
- 1 Divisao de Pneumologia, Instituto do Coracao (Incor), Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Cristhiano A S Lima
- 1 Divisao de Pneumologia, Instituto do Coracao (Incor), Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Ozires P S Ramos
- 1 Divisao de Pneumologia, Instituto do Coracao (Incor), Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Sérgio M Pereira
- 1 Divisao de Pneumologia, Instituto do Coracao (Incor), Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Naomasa Kawaguchi
- 4 The Department of Pathology, School of Allied Health Sciences, Osaka University Graduate School of Medicine, Suita, Japan
| | - Hirofumi Yamamoto
- 4 The Department of Pathology, School of Allied Health Sciences, Osaka University Graduate School of Medicine, Suita, Japan
| | | | - João B Borges
- 5 Hedenstierna Laboratory, Department of Surgical Sciences, Section of Anesthesiology & Critical Care, Uppsala University, Uppsala, Sweden; and
| | - Marcos F Vidal Melo
- 6 Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard University, Boston, Massachusetts
| | - Mauro R Tucci
- 1 Divisao de Pneumologia, Instituto do Coracao (Incor), Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Marcelo B P Amato
- 1 Divisao de Pneumologia, Instituto do Coracao (Incor), Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Brian P Kavanagh
- 3 Translational Medicine, Departments of Critical Care Medicine and Anesthesia, Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Eduardo L V Costa
- 1 Divisao de Pneumologia, Instituto do Coracao (Incor), Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Yuji Fujino
- 2 Intensive Care Unit, Osaka University Hospital, Suita, Japan
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375
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Piquilloud L, Beloncle F, Richard JCM, Mancebo J, Mercat A, Brochard L. Information conveyed by electrical diaphragmatic activity during unstressed, stressed and assisted spontaneous breathing: a physiological study. Ann Intensive Care 2019; 9:89. [PMID: 31414251 PMCID: PMC6692797 DOI: 10.1186/s13613-019-0564-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Accepted: 07/31/2019] [Indexed: 11/13/2022] Open
Abstract
Background The electrical activity of the crural diaphragm (Eadi), a surrogate of respiratory drive, can now be measured at the bedside in mechanically ventilated patients with a specific catheter. The expected range of Eadi values under stressed or assisted spontaneous breathing is unknown. This study explored Eadi values in healthy subjects during unstressed (baseline), stressed (with a resistance) and assisted spontaneous breathing. The relation between Eadi and inspiratory effort was analyzed. Methods Thirteen healthy male volunteers were included in this randomized crossover study. Eadi and esophageal pressure (Peso) were recorded during unstressed and stressed spontaneous breathing and under assisted ventilation delivered in pressure support (PS) at low and high assist levels and in neurally adjusted ventilatory assist (NAVA). Overall eight different situations were assessed in each participant (randomized order). Peak, mean and integral of Eadi, breathing pattern, esophageal pressure–time product (PTPeso) and work of breathing (WOB) were calculated offline. Results Median [interquartile range] peak Eadi at baseline was 17 [13–22] μV and was above 10 μV in 92% of the cases. Eadimax defined as Eadi measured at maximal inspiratory capacity reached 90 [63 to 99] μV. Median peak Eadi/Eadimax ratio was 16.8 [15.6–27.9]%. Compared to baseline, respiratory rate and minute ventilation were decreased during stressed non-assisted breathing, whereas peak Eadi and PTPeso were increased. During unstressed assisted breathing, peak Eadi decreased during high-level PS compared to unstressed non-assisted breathing and to NAVA (p = 0.047). During stressed breathing, peak Eadi was lower during all assisted ventilation modalities compared to stressed non-assisted breathing. During assisted ventilation, across the different conditions, peak Eadi changed significantly, whereas PTPeso and WOB/min were not significantly modified. Finally, Eadi signal was still present even when Peso signal was suppressed due to high assist levels. Conclusion Eadi analysis provides complementary information compared to respiratory pattern and to Peso monitoring, particularly in the presence of high assist levels. Trial registration The study was registered as NCT01818219 in clinicaltrial.gov. Registered 28 February 2013 Electronic supplementary material The online version of this article (10.1186/s13613-019-0564-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Lise Piquilloud
- Medical Intensive Care Department, University Hospital of Angers, University of Angers, 4, Rue Larrey, 49100, Angers, France. .,Adult Intensive Care and Burn Unit, University Hospital and University of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Switzerland.
| | - François Beloncle
- Medical Intensive Care Department, University Hospital of Angers, University of Angers, 4, Rue Larrey, 49100, Angers, France
| | - Jean-Christophe M Richard
- SAMU74, Emergency Department, General Hospital of Annecy, 1, Av de l'hôpital, 74370, Epagny Metz-Tessy, France.,INSERM, UMR 955, Créteil, France
| | - Jordi Mancebo
- Intensive Care Department, Sant Pau Hospital, Carrer de Sant Quinti 89, 08041, Barcelona, Spain
| | - Alain Mercat
- Medical Intensive Care Department, University Hospital of Angers, University of Angers, 4, Rue Larrey, 49100, Angers, France
| | - Laurent Brochard
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.,Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, Toronto, ON, M5B 1T8, Canada
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376
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Dexmedetomidine Impairs Diaphragm Function and Increases Oxidative Stress but Does Not Aggravate Diaphragmatic Atrophy in Mechanically Ventilated Rats. Anesthesiology 2019; 128:784-795. [PMID: 29346133 DOI: 10.1097/aln.0000000000002081] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Anesthetics in ventilated patients are critical as any cofactor hampering diaphragmatic function may have a negative impact on the weaning progress and therefore on patients' mortality. Dexmedetomidine may display antioxidant and antiproteolytic properties, but it also reduced glucose uptake by the muscle, which may impair diaphragm force production. This study tested the hypothesis that dexmedetomidine could inhibit ventilator-induced diaphragmatic dysfunction. METHODS Twenty-four rats were separated into three groups (n = 8/group). Two groups were mechanically ventilated during either dexmedetomidine or pentobarbital exposure for 24 h, referred to as interventional groups. A third group of directly euthanized rats served as control. Force generation, fiber dimensions, proteolysis markers, protein oxidation and lipid peroxidation, calcium homeostasis markers, and glucose transporter-4 (Glut-4) translocation were measured in the diaphragm. RESULTS Diaphragm force, corrected for cross-sectional area, was significantly decreased in both interventional groups compared to controls and was significantly lower with dexmedetomidine compared to pentobarbital (e.g., 100 Hz: -18%, P < 0.0001). In contrast to pentobarbital, dexmedetomidine did not lead to diaphragmatic atrophy, but it induced more protein oxidation (200% vs. 73% in pentobarbital, P = 0.0015), induced less upregulation of muscle atrophy F-box (149% vs. 374% in pentobarbital, P < 0.001) and impaired Glut-4 translocation (-73%, P < 0.0005). It activated autophagy, the calcium-dependent proteases, and caused lipid peroxidation similarly to pentobarbital. CONCLUSIONS Twenty-four hours of mechanical ventilation during dexmedetomidine sedation led to a worsening of ventilation-induced diaphragm dysfunction, possibly through impaired Glut-4 translocation. Although dexmedetomidine prevented diaphragmatic fiber atrophy, it did not inhibit oxidative stress and activation of the proteolytic pathways.
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377
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Peñuelas O, Keough E, López-Rodríguez L, Carriedo D, Gonçalves G, Barreiro E, Lorente JÁ. Ventilator-induced diaphragm dysfunction: translational mechanisms lead to therapeutical alternatives in the critically ill. Intensive Care Med Exp 2019; 7:48. [PMID: 31346802 PMCID: PMC6658639 DOI: 10.1186/s40635-019-0259-9] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Accepted: 05/23/2019] [Indexed: 02/08/2023] Open
Abstract
Mechanical ventilation [MV] is a life-saving technique delivered to critically ill patients incapable of adequately ventilating and/or oxygenating due to respiratory or other disease processes. This necessarily invasive support however could potentially result in important iatrogenic complications. Even brief periods of MV may result in diaphragm weakness [i.e., ventilator-induced diaphragm dysfunction [VIDD]], which may be associated with difficulty weaning from the ventilator as well as mortality. This suggests that VIDD could potentially have a major impact on clinical practice through worse clinical outcomes and healthcare resource use. Recent translational investigations have identified that VIDD is mainly characterized by alterations resulting in a major decline of diaphragmatic contractile force together with atrophy of diaphragm muscle fibers. However, the signaling mechanisms responsible for VIDD have not been fully established. In this paper, we summarize the current understanding of the pathophysiological pathways underlying VIDD and highlight the diagnostic approach, as well as novel and experimental therapeutic options.
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Affiliation(s)
- Oscar Peñuelas
- Intensive Care Unit, Hospital Universitario de Getafe, Carretera de Toledo, km 12.5, 28905, Getafe, Madrid, Spain.
- Centro de Investigación en Red de Enfermedades Respiratorias [CIBERES], Instituto de Salud Carlos III [ISCIII], Madrid, Spain.
| | - Elena Keough
- Intensive Care Unit, Hospital Universitario de Getafe, Carretera de Toledo, km 12.5, 28905, Getafe, Madrid, Spain
| | - Lucía López-Rodríguez
- Intensive Care Unit, Hospital Universitario de Getafe, Carretera de Toledo, km 12.5, 28905, Getafe, Madrid, Spain
| | - Demetrio Carriedo
- Intensive Care Unit, Hospital Universitario de Getafe, Carretera de Toledo, km 12.5, 28905, Getafe, Madrid, Spain
| | - Gesly Gonçalves
- Intensive Care Unit, Hospital Universitario de Getafe, Carretera de Toledo, km 12.5, 28905, Getafe, Madrid, Spain
| | - Esther Barreiro
- Centro de Investigación en Red de Enfermedades Respiratorias [CIBERES], Instituto de Salud Carlos III [ISCIII], Madrid, Spain
- Pulmonology Department-Muscle Wasting and Cachexia in Chronic Respiratory Diseases and Lung Cancer Research Group, IMIM-Hospital del Mar, Parc de Salut Mar, Health and Experimental Sciences Department [CEXS], Barcelona, Spain
- Universitat Pompeu Fabra [UPF], Barcelona Biomedical Research Park [PRBB], Barcelona, Spain
| | - José Ángel Lorente
- Intensive Care Unit, Hospital Universitario de Getafe, Carretera de Toledo, km 12.5, 28905, Getafe, Madrid, Spain
- Centro de Investigación en Red de Enfermedades Respiratorias [CIBERES], Instituto de Salud Carlos III [ISCIII], Madrid, Spain
- Universidad Europea, Madrid, Spain
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378
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McCaughey EJ, Jonkman AH, Boswell-Ruys CL, McBain RA, Bye EA, Hudson AL, Collins DW, Heunks LMA, McLachlan AJ, Gandevia SC, Butler JE. Abdominal functional electrical stimulation to assist ventilator weaning in critical illness: a double-blinded, randomised, sham-controlled pilot study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:261. [PMID: 31340846 PMCID: PMC6657036 DOI: 10.1186/s13054-019-2544-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Accepted: 07/16/2019] [Indexed: 01/15/2023]
Abstract
Background For every day a person is dependent on mechanical ventilation, respiratory and cardiac complications increase, quality of life decreases and costs increase by > $USD 1500. Interventions that improve respiratory muscle function during mechanical ventilation can reduce ventilation duration. The aim of this pilot study was to assess the feasibility of employing an abdominal functional electrical stimulation (abdominal FES) training program with critically ill mechanically ventilated patients. We also investigated the effect of abdominal FES on respiratory muscle atrophy, mechanical ventilation duration and intensive care unit (ICU) length of stay. Methods Twenty critically ill mechanically ventilated participants were recruited over a 6-month period from one metropolitan teaching hospital. They were randomly assigned to receive active or sham (control) abdominal FES for 30 min, twice per day, 5 days per week, until ICU discharge. Feasibility was assessed through participant compliance to stimulation sessions. Abdominal and diaphragm muscle thickness were measured using ultrasound 3 times in the first week, and weekly thereafter by a blinded assessor. Respiratory function was recorded when the participant could first breathe independently and at ICU discharge, with ventilation duration and ICU length of stay also recorded at ICU discharge by a blinded assessor. Results Fourteen of 20 participants survived to ICU discharge (8, intervention; 6, control). One control was transferred before extubation, while one withdrew consent and one was withdrawn for staff safety after extubation. Median compliance to stimulation sessions was 92.1% (IQR 5.77%) in the intervention group, and 97.2% (IQR 7.40%) in the control group (p = 0.384). While this pilot study is not adequately powered to make an accurate statistical conclusion, there appeared to be no between-group thickness changes of the rectus abdominis (p = 0.099 at day 3), diaphragm (p = 0.652 at day 3) or combined lateral abdominal muscles (p = 0.074 at day 3). However, ICU length of stay (p = 0.011) and ventilation duration (p = 0.039) appeared to be shorter in the intervention compared to the control group. Conclusions Our compliance rates demonstrate the feasibility of using abdominal FES with critically ill mechanically ventilated patients. While abdominal FES did not lead to differences in abdominal muscle or diaphragm thickness, it may be an effective method to reduce ventilation duration and ICU length of stay in this patient group. A fully powered study into this effect is warranted. Trial registration The Australian New Zealand Clinical Trials Registry, ACTRN12617001180303. Registered 9 August 2017.
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Affiliation(s)
- Euan J McCaughey
- Neuroscience Research Australia, 139 Barker Street, Randwick, NSW, 2031, Australia. .,School of Medical Sciences, University of New South Wales, Kensington, NSW, 2052, Australia.
| | - Annemijn H Jonkman
- Department of Intensive Care Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan, 1117, Amsterdam, The Netherlands
| | - Claire L Boswell-Ruys
- Neuroscience Research Australia, 139 Barker Street, Randwick, NSW, 2031, Australia.,School of Medical Sciences, University of New South Wales, Kensington, NSW, 2052, Australia.,Prince of Wales Hospital, Randwick, NSW, 2031, Australia
| | - Rachel A McBain
- Neuroscience Research Australia, 139 Barker Street, Randwick, NSW, 2031, Australia.,School of Medical Sciences, University of New South Wales, Kensington, NSW, 2052, Australia.,Prince of Wales Hospital, Randwick, NSW, 2031, Australia
| | - Elizabeth A Bye
- Neuroscience Research Australia, 139 Barker Street, Randwick, NSW, 2031, Australia.,School of Medical Sciences, University of New South Wales, Kensington, NSW, 2052, Australia.,Prince of Wales Hospital, Randwick, NSW, 2031, Australia
| | - Anna L Hudson
- Neuroscience Research Australia, 139 Barker Street, Randwick, NSW, 2031, Australia.,School of Medical Sciences, University of New South Wales, Kensington, NSW, 2052, Australia
| | | | - Leo M A Heunks
- Department of Intensive Care Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan, 1117, Amsterdam, The Netherlands
| | - Angus J McLachlan
- Liberate Medical LLC, 6400 Westwind Way, Suite A, Crestwood, KY, 40014, USA
| | - Simon C Gandevia
- Neuroscience Research Australia, 139 Barker Street, Randwick, NSW, 2031, Australia.,School of Medical Sciences, University of New South Wales, Kensington, NSW, 2052, Australia.,Prince of Wales Hospital, Randwick, NSW, 2031, Australia
| | - Jane E Butler
- Neuroscience Research Australia, 139 Barker Street, Randwick, NSW, 2031, Australia.,School of Medical Sciences, University of New South Wales, Kensington, NSW, 2052, Australia
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379
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Maggiore SM, Battilana M, Serano L, Petrini F. Ventilatory support after extubation in critically ill patients. THE LANCET RESPIRATORY MEDICINE 2019; 6:948-962. [PMID: 30629933 DOI: 10.1016/s2213-2600(18)30375-8] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 09/06/2018] [Accepted: 09/07/2018] [Indexed: 12/29/2022]
Abstract
The periextubation period represents a crucial moment in the management of critically ill patients. Extubation failure, defined as the need for reintubation within 2-7 days after a planned extubation, is associated with prolonged mechanical ventilation, increased incidence of ventilator-associated pneumonia, longer intensive care unit and hospital stays, and increased mortality. Conventional oxygen therapy is commonly used after extubation. Additional methods of non-invasive respiratory support, such as non-invasive ventilation and high-flow nasal therapy, can be used to avoid reintubation. The aim of this Review is to describe the pathophysiological mechanisms of postextubation respiratory failure and the available techniques and strategies of respiratory support to avoid reintubation. We summarise and discuss the available evidence supporting the use of these strategies to achieve a tailored therapy for an individual patient at the bedside.
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Affiliation(s)
- Salvatore Maurizio Maggiore
- University Department of Medical, Oral and Biotechnological Sciences, Gabriele d'Annunzio University of Chieti-Pescara, Chieti, Italy; Clinical Department of Anaesthesiology and Intensive Care Medicine, SS. Annunziata Hospital, Chieti, Italy.
| | - Mariangela Battilana
- University Department of Medical, Oral and Biotechnological Sciences, Gabriele d'Annunzio University of Chieti-Pescara, Chieti, Italy
| | - Luca Serano
- University Department of Medical, Oral and Biotechnological Sciences, Gabriele d'Annunzio University of Chieti-Pescara, Chieti, Italy
| | - Flavia Petrini
- University Department of Medical, Oral and Biotechnological Sciences, Gabriele d'Annunzio University of Chieti-Pescara, Chieti, Italy; Clinical Department of Anaesthesiology and Intensive Care Medicine, SS. Annunziata Hospital, Chieti, Italy
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380
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Nava S, Pisani L. Patient-Clinician Alliance during Prolonged Mechanical Ventilation. "Never Give Up on a Dream". Am J Respir Crit Care Med 2019; 199:1453-1454. [PMID: 30896966 PMCID: PMC6580677 DOI: 10.1164/rccm.201901-0032ed] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Stefano Nava
- 1 Sant'Orsola Malpighi Hospital Alma Mater Studiorum, University of Bologna Bologna, Italy
| | - Lara Pisani
- 1 Sant'Orsola Malpighi Hospital Alma Mater Studiorum, University of Bologna Bologna, Italy
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381
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382
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Shekar K, Abrams D, Schmidt M. Awake extracorporeal membrane oxygenation in immunosuppressed patients with severe respiratory failure-a stretch too far? J Thorac Dis 2019; 11:2656-2659. [PMID: 31463086 DOI: 10.21037/jtd.2019.05.58] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Kiran Shekar
- Adult Intensive Care Services and Critical Care Research Group, the Prince Charles Hospital, Brisbane, Queensland, Australia.,University of Queensland and Bond University, Queensland, Australia
| | - Darryl Abrams
- Columbia University College of Physicians & Surgeons/New York-Presbyterian Hospital, New York, NY, USA.,Center for Acute Respiratory Failure, Columbia University Medical Center, New York, NY, USA
| | - Matthieu Schmidt
- Sorbonne Université, INSERM UMRS_1166-iCAN, Institute of Cardiometabolism and Nutrition, Paris, France.,Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Medical Intensive Care Unit, Paris, France
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383
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Zhang Z, Xue Y, Li HH, Li YM. [Research advances in validity of predictors for extubation outcome in children receiving invasive mechanical ventilation]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2019; 21:730-734. [PMID: 31315777 PMCID: PMC7389097 DOI: 10.7499/j.issn.1008-8830.2019.07.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Accepted: 04/25/2019] [Indexed: 06/10/2023]
Abstract
The development of invasive mechanical ventilation technology provides effective respiratory support for critically ill children. However, respiratory support is not the end of treatment as the ultimate goal is successful extubation in children. At present, some evaluation indicators before extubation including rapid shallow breathing index, maximal inspiratory pressure, and work of breathing are of high clinical value in predicting adult extubation outcome, but their evidence of evidence-based medicine is not sufficient in the field of pediatric intensive care. This paper reviews the current research on the validity of predictors for extubation outcomes in children. It shows that there is still a lack of indicators with good sensitivity and specificity for assessment before extubation in children. The studies are still in a small-sample size and single-center stage. Therefore, how to optimize evaluation before extubation and improve the success rate of extubation is the direction of joint efforts of doctors in the pediatric intensive care unit and rehabilitation medicine department.
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Affiliation(s)
- Zhen Zhang
- Pediatric Intensive Care Unit, First Hospital of Jilin University, Changchun 130021, China.
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384
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Douglas IS, Bednash JS, Fein DG, Mallampalli RK, Mansoori JN, Gershengorn HB. Update in Critical Care and Acute Respiratory Distress Syndrome 2018. Am J Respir Crit Care Med 2019; 199:1335-1343. [PMID: 30958975 PMCID: PMC12042184 DOI: 10.1164/rccm.201903-0550up] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 04/04/2019] [Indexed: 01/16/2023] Open
Affiliation(s)
- Ivor S. Douglas
- Pulmonary, Sleep and Critical Care Medicine, Department of Medicine, Denver Health Medical Center, Denver, Colorado
| | - Joseph S. Bednash
- Acute Lung Injury Center of Excellence, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | | | - Jason N. Mansoori
- Pulmonary, Sleep and Critical Care Medicine, Department of Medicine, Denver Health Medical Center, Denver, Colorado
| | - Hayley B. Gershengorn
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Miller School of Medicine, University of Miami, Miami, Florida
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385
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Goligher EC. Myotrauma in mechanically ventilated patients. Intensive Care Med 2019; 45:881-884. [PMID: 30741329 DOI: 10.1007/s00134-019-05557-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Accepted: 02/02/2019] [Indexed: 10/27/2022]
Affiliation(s)
- Ewan C Goligher
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.
- Department of Medicine, Division of Respirology, University Health Network, Toronto, Canada.
- Toronto General Hospital Research Institute, 585 University Ave., 11-PMB Room 192, Toronto, ON, M5G 2N2, Canada.
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386
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387
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Rittayamai N, Hemvimon S, Chierakul N. The evolution of diaphragm activity and function determined by ultrasound during spontaneous breathing trials. J Crit Care 2019; 51:133-138. [DOI: 10.1016/j.jcrc.2019.02.016] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Revised: 02/10/2019] [Accepted: 02/11/2019] [Indexed: 11/28/2022]
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388
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Jonkman AH, Jansen D, Gadgil S, Keijzer C, Girbes ARJ, Scheffer GJ, van der Hoeven JG, Tuinman PR, Spoelstra-de Man AME, Sinderby CS, Heunks LMA. Monitoring patient-ventilator breath contribution in the critically ill during neurally adjusted ventilatory assist: reliability and improved algorithms for bedside use. J Appl Physiol (1985) 2019; 127:264-271. [PMID: 31161879 DOI: 10.1152/japplphysiol.00071.2019] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
The patient-ventilator breath contribution (PVBC) index estimates the relative contribution of the patient to total tidal volume (Vtinsp) during mechanical ventilation in neurally adjusted ventilator assist mode and has been used to titrate ventilator support. The reliability of this index in ventilated patients is unknown and was investigated in this study. PVBC was calculated by comparing tidal volume (Vtinsp) and diaphragm electrical activity (EAdi) during assisted breaths (Vtinsp/EAdi)assist and during unassisted breaths (Vtinsp/EAdi)no-assist. Vtinsp was normalized to peak EAdi (EAdipeak) using 1) one assisted breath, 2) five consecutive assisted breaths, or 3) five assisted breaths with matching EAdi preceding the unassisted breath (N1PVBC2, X5PVBC2, and PX5VBCEAdi-matching2 , respectively). In addition, PVBC was calculated by comparing only Vtinsp for breaths with matching EAdi (PVBCβ2). Test-retest reliability of the different PVBC calculation methods was evaluated with the intraclass correlation coefficient (ICC) using five repeated PVBC maneuvers performed with a 1-min interval. In total, 125 PVBC maneuvers were analyzed in 25 patients. ICC [95% confidence interval] values were 0.46 [0.23-0.66], 0.51 [0.33-0.70], and 0.42 [0.14-0.69] for N1PVBC2, X5PVBC2, PX5VBCEAdi-matching2 , respectively. Complex waveform analyses showed that insufficient EAdi filtering by the ventilator software affects reliability of PVBC calculation. With our new EAdi-matching techniques reliability improved (PVBCβ2 ICC: 0.78 [0.60-0.90]). We conclude that current techniques to calculate PVBC exhibit low reliability and that our newly developed criteria and estimation of PVBC-using Vtinsp of assisted breaths and unassisted breaths with matching EAdi-improves reliability. This may help implementation of PVBC in clinical practice. NEW & NOTEWORTHY The patient-ventilator breath contribution (PVBC) index estimates the relative contribution of the patient to tidal volume generated by the patient and the mechanical ventilator during mechanical ventilation in neurally adjusted ventilator assist mode. It could be used to titrate ventilator support and thus to limit development of diaphragm dysfunction in intensive care unit patients. Currently available methods for bedside assessment of PVBC are unreliable. Our newly developed criteria and estimation of PVBC largely improve reliability and help to quantify patient contribution to total inspiratory effort.
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Affiliation(s)
- Annemijn H Jonkman
- Department of Intensive Care Medicine, Amsterdam UMC, location VUmc, Amsterdam , The Netherlands
| | - Diana Jansen
- Department of Anesthesiology, Radboud University Medical Center , Nijmegen , The Netherlands
| | - Suvarna Gadgil
- Department of Anesthesiology, University Medical Center Utrecht , Utrecht , The Netherlands
| | - Christiaan Keijzer
- Department of Anesthesiology, Radboud University Medical Center , Nijmegen , The Netherlands
| | - Armand R J Girbes
- Department of Intensive Care Medicine, Amsterdam UMC, location VUmc, Amsterdam , The Netherlands
| | - Gert-Jan Scheffer
- Department of Anesthesiology, Radboud University Medical Center , Nijmegen , The Netherlands
| | - Johannes G van der Hoeven
- Department of Intensive Care Medicine, Radboud University Medical Center , Nijmegen , The Netherlands
| | - Pieter Roel Tuinman
- Department of Intensive Care Medicine, Amsterdam UMC, location VUmc, Amsterdam , The Netherlands
| | | | - Christer S Sinderby
- Department of Critical Care Medicine, St. Michael's Hospital, University of Toronto , Toronto, Ontario , Canada
| | - Leo M A Heunks
- Department of Intensive Care Medicine, Amsterdam UMC, location VUmc, Amsterdam , The Netherlands
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389
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Heunks L, Ottenheijm C. Diaphragm-Protective Mechanical Ventilation to Improve Outcomes in ICU Patients? Am J Respir Crit Care Med 2019; 197:150-152. [PMID: 29182892 DOI: 10.1164/rccm.201710-2002ed] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Leo Heunks
- 1 Department of Intensive Care VU University Medical Centre Amsterdam Amsterdam, the Netherlands
| | - Coen Ottenheijm
- 2 Department of Physiology VU University Medical Centre Amsterdam Amsterdam, the Netherlands and.,3 Department of Cellular and Molecular Medicine University of Arizona Tucson, Arizona
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390
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van der Pijl RJ, Granzier HL, Ottenheijm CAC. Diaphragm contractile weakness due to reduced mechanical loading: role of titin. Am J Physiol Cell Physiol 2019; 317:C167-C176. [PMID: 31042425 DOI: 10.1152/ajpcell.00509.2018] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The diaphragm, the main muscle of inspiration, is constantly subjected to mechanical loading. Only during controlled mechanical ventilation, as occurs during thoracic surgery and in the intensive care unit, is mechanical loading of the diaphragm arrested. Animal studies indicate that the diaphragm is highly sensitive to unloading, causing rapid muscle fiber atrophy and contractile weakness; unloading-induced diaphragm atrophy and contractile weakness have been suggested to contribute to the difficulties in weaning patients from ventilator support. The molecular triggers that initiate the rapid unloading atrophy of the diaphragm are not well understood, although proteolytic pathways and oxidative signaling have been shown to be involved. Mechanical stress is known to play an important role in the maintenance of muscle mass. Within the muscle's sarcomere, titin is considered to play an important role in the stress-response machinery. Titin is a giant protein that acts as a mechanosensor regulating muscle protein expression in a sarcomere strain-dependent fashion. Thus titin is an attractive candidate for sensing the sudden mechanical arrest of the diaphragm when patients are mechanically ventilated, leading to changes in muscle protein expression. Here, we provide a novel perspective on how titin and its biomechanical sensing and signaling might be involved in the development of mechanical unloading-induced diaphragm weakness.
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Affiliation(s)
- Robbert J van der Pijl
- Department of Cellular and Molecular Medicine, University of Arizona , Tucson, Arizona.,Department of Physiology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Henk L Granzier
- Department of Cellular and Molecular Medicine, University of Arizona , Tucson, Arizona
| | - Coen A C Ottenheijm
- Department of Cellular and Molecular Medicine, University of Arizona , Tucson, Arizona.,Department of Physiology, Amsterdam University Medical Center, Amsterdam, The Netherlands
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391
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Moury PH, Cuisinier A, Durand M, Bosson JL, Chavanon O, Payen JF, Jaber S, Albaladejo P. Diaphragm thickening in cardiac surgery: a perioperative prospective ultrasound study. Ann Intensive Care 2019; 9:50. [PMID: 31016412 PMCID: PMC6478777 DOI: 10.1186/s13613-019-0521-z] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Accepted: 04/04/2019] [Indexed: 02/07/2023] Open
Abstract
Background Diaphragm paresis is common after cardiac surgery and may delay the weaning from the ventilator. Our objective was to evaluate diaphragm thickening during weaning and secondly the muscle thickness as a marker of myotrauma. Methods Patients undergoing elective cardiac surgery were prospectively included. Ultrasonic index of right hemidiaphragm thickening fraction (TF) was measured as a surrogate criterion of work of breathing. A TF < 20% was defined as a low diaphragm thickening. Measurements of TF were performed during three periods to study diaphragm thickening evolution defined by the difference between two consecutive time line point: preoperative (D − 1), during a spontaneous breathing trial (SBT) in the intensive care unit and postoperative (D + 1). We studied three patterns of diaphragm thickness at end expiration evolution from D − 1 to D + 1: > 10% decrease, stability and > 10% increase. Demographical data, length of surgery, type of surgery, ICU length of stay (LOS) and extubation failure were collected. Results Of the 100 consecutively included patients, 75 patients had a low diaphragm thickening during SBT. Compared to TF values at D − 1 (36% ± 18), TF was reduced during SBT (17% ± 14) and D + 1 (12% ± 11) (P < 0.0001). Thickness and TF did not change according to the type of surgery or cooling method. TF at SBT was correlated to the length of surgery (both r = − 0.4; P < 0.0001). Diaphragm thickness as continuous variable did not change over time. Twenty-eight patients (42%) had a > 10% decrease thickness, 19 patients (29%) stability and 19 patients (28%) in > 10% increase, and this thickness evolution pattern was associated with: a longer LOS 3 days [2–5] versus 2 days [2–4] and 2 days [2], respectively (ANOVA P = 0.046), and diaphragm thickening evolution (ANOVA P = 0.02). Two patients experience extubation failure. Conclusion These findings indicate that diaphragm thickening is frequently decreased after elective cardiac surgery without impact on respiratory outcome, whereas an altered thickness pattern was associated with a longer length of stay in the ICU. Contractile activity influenced thickness evolution. Trial registry number ClinicalTrial.gov ID NCT02208479 Electronic supplementary material The online version of this article (10.1186/s13613-019-0521-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Pierre-Henri Moury
- Department of Anesthesia and Intensive Care Medicine, Université Grenoble-Alpes, Grenoble University Hospital, Grenoble, France.
| | - Adrien Cuisinier
- Department of Anesthesia and Intensive Care Medicine, Université Grenoble-Alpes, Grenoble University Hospital, Grenoble, France
| | - Michel Durand
- Department of Anesthesia and Intensive Care Medicine, Université Grenoble-Alpes, Grenoble University Hospital, Grenoble, France
| | - Jean-Luc Bosson
- Department of Biostatistics, ThEMAS, TIMC, UMR, CNRS 5525, Université Grenoble Alpes, Grenoble University Hospital, Grenoble, France
| | - Olivier Chavanon
- Department of Cardiac Surgery, Université Grenoble Alpes, Grenoble University Hospital, Grenoble, France
| | - Jean-François Payen
- Department of Anesthesia and Intensive Care Medicine, Université Grenoble-Alpes, Grenoble University Hospital, Grenoble, France
| | - Samir Jaber
- Intensive Care Unit, Anesthesiology and Critical Care Department B, Saint Eloi Teaching Hospital, Université Montpellier 1, Centre Hospitalier Universitaire Montpellier, Montpellier, France
| | - Pierre Albaladejo
- Department of Anesthesia and Intensive Care, ThEMAS, TIMC, UMR, CNRS 5525, Université Grenoble-Alpes, Grenoble University Hospital, Grenoble, France
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392
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Abstract
PURPOSE OF REVIEW Esophageal manometry has shown its usefulness to estimate transpulmonary pressure, that is lung stress, and the intensity of spontaneous effort in patients with acute respiratory distress syndrome. However, clinical uptake of esophageal manometry in ICU is still low. Thus, the purpose of review is to describe technical tips to adequately measure esophageal pressure at the bedside, and then update the most important clinical applications of esophageal manometry in ICU. RECENT FINDINGS Each esophageal balloon has its own nonstressed volume and it should be calibrated properly to measure pleural pressure accurately: transpulmonary pressure calculated on absolute esophageal pressure reflects values in the lung regions adjacent to the esophageal balloon (i.e. dependent to middle lung). Inspiratory transpulmonary pressure calculated from airway plateau pressure and the chest wall to respiratory system elastance ratio reasonably reflects lung stress in the nondependent 'baby' lung, at highest risk of hyperinflation. Also esophageal pressure can be used to detect and minimize patient self-inflicted lung injury. SUMMARY Esophageal manometry is not a complicated technique. There is a large potential to improve clinical outcome in patients with acute respiratory distress syndrome, acting as an early detector of risk of lung injury from mechanical ventilation and vigorous spontaneous effort.
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393
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Kollisch-Singule M, Andrews P, Satalin J, Gatto LA, Nieman GF, Habashi NM. The time-controlled adaptive ventilation protocol: mechanistic approach to reducing ventilator-induced lung injury. Eur Respir Rev 2019; 28:28/152/180126. [PMID: 30996041 DOI: 10.1183/16000617.0126-2018] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Accepted: 02/16/2019] [Indexed: 11/05/2022] Open
Abstract
Airway pressure release ventilation (APRV) is a ventilator mode that has previously been considered a rescue mode, but has gained acceptance as a primary mode of ventilation. In clinical series and experimental animal models of extrapulmonary acute respiratory distress syndrome (ARDS), the early application of APRV was able to prevent the development of ARDS. Recent experimental evidence has suggested mechanisms by which APRV, using the time-controlled adaptive ventilation (TCAV) protocol, may reduce lung injury, including: 1) an improvement in alveolar recruitment and homogeneity; 2) reduction in alveolar and alveolar duct micro-strain and stress-risers; 3) reduction in alveolar tidal volumes; and 4) recruitment of the chest wall by combating increased intra-abdominal pressure. This review examines these studies and discusses our current understanding of the pleiotropic mechanisms by which TCAV protects the lung. APRV set according to the TCAV protocol has been misunderstood and this review serves to highlight the various protective physiological and mechanical effects it has on the lung, so that its clinical application may be broadened.
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Affiliation(s)
| | - Penny Andrews
- Dept of Trauma Critical Care Medicine, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Joshua Satalin
- Dept of Surgery, SUNY Upstate Medical University, Syracuse, NY, USA
| | - Louis A Gatto
- Dept of Surgery, SUNY Upstate Medical University, Syracuse, NY, USA.,Dept of Biological Sciences, SUNY Cortland, Cortland, NY, USA
| | - Gary F Nieman
- Dept of Surgery, SUNY Upstate Medical University, Syracuse, NY, USA
| | - Nader M Habashi
- Dept of Trauma Critical Care Medicine, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
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394
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Tang H, Shrager JB. The Signaling Network Resulting in Ventilator-induced Diaphragm Dysfunction. Am J Respir Cell Mol Biol 2019; 59:417-427. [PMID: 29768017 DOI: 10.1165/rcmb.2018-0022tr] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Mechanical ventilation (MV) is a life-saving measure for those incapable of adequately ventilating or oxygenating without assistance. Unfortunately, even brief periods of MV result in diaphragm weakness (i.e., ventilator-induced diaphragm dysfunction [VIDD]) that may render it difficult to wean the ventilator. Prolonged MV is associated with cascading complications and is a strong risk factor for death. Thus, prevention of VIDD may have a dramatic impact on mortality rates. Here, we summarize the current understanding of the pathogenic events underlying VIDD. Numerous alterations have been proven important in both human and animal MV diaphragm. These include protein degradation via the ubiquitin proteasome system, autophagy, apoptosis, and calpain activity-all causing diaphragm muscle fiber atrophy, altered energy supply via compromised oxidative phosphorylation and upregulation of glycolysis, and also mitochondrial dysfunction and oxidative stress. Mitochondrial oxidative stress in fact appears to be a central factor in each of these events. Recent studies by our group and others indicate that mitochondrial function is modulated by several signaling molecules, including Smad3, signal transducer and activator of transcription 3, and FoxO. MV rapidly activates Smad3 and signal transducer and activator of transcription 3, which upregulate mitochondrial oxidative stress. Additional roles may be played by angiotensin II and leaky ryanodine receptors causing elevated calcium levels. We present, here, a hypothetical scaffold for understanding the molecular pathogenesis of VIDD, which links together these elements. These pathways harbor several drug targets that could soon move toward testing in clinical trials. We hope that this review will shape a short list of the most promising candidates.
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Affiliation(s)
- Huibin Tang
- Stanford University School of Medicine, Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford, California; and Veterans Affairs Palo Alto Healthcare System, Palo Alto, California
| | - Joseph B Shrager
- Stanford University School of Medicine, Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford, California; and Veterans Affairs Palo Alto Healthcare System, Palo Alto, California
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395
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Fisser C, Spoletini G, Soe AK, Livesey A, Schreiber A, Swingwood E, Bos LD, Dreher M, Schultz MJ, Heunks L, Scala R. European Respiratory Society International Congress 2018: highlights from Assembly 2 on respiratory intensive care. ERJ Open Res 2019; 5:00198-2018. [PMID: 30847349 PMCID: PMC6397914 DOI: 10.1183/23120541.00198-2018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Accepted: 01/28/2019] [Indexed: 12/14/2022] Open
Abstract
The respiratory intensive care Assembly of the European Respiratory Society is proud to present a summary of several important sessions held at the International Congress in Paris in 2018. For the highly esteemed reader who may have missed the Congress, a concise review was written on three topics: the state-of-the-art session on respiratory critical care, hot topics in weaning and the best abstracts in noninvasive ventilation. The respiratory intensive care Assembly of the European Respiratory Society is proud to present a summary of several important sessions from the 2018 #ERSCongress in Parishttp://ow.ly/6Du830nFESK
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Affiliation(s)
- Christoph Fisser
- Dept of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany.,Dept of Pneumology, Hospital Donaustauf, Donaustauf, Germany
| | - Giulia Spoletini
- Respiratory Dept, St James's University Hospital, Leeds Teaching Hospital NHS Trust, Leeds, UK.,Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, UK
| | - Aung Kyaw Soe
- Dept of Hospital Therapy, Pediatric Faculty, Pirogov Russian National Research Medical University, Moscow, Russian Federation
| | - Alana Livesey
- Heartlands Hospital, University Hospitals Birmingham, Birmingham, UK
| | - Annia Schreiber
- Dept of Medicine, Division of Respirology, University Health Network, Toronto, ON, Canada
| | - Ema Swingwood
- Physiotherapy Dept - Adult Therapy Services, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Lieuwe D Bos
- Dept of Intensive Care, Amsterdam UMC, location AMC, Amsterdam, The Netherlands
| | - Michael Dreher
- Dept of Pneumology and Intensive Care Medicine, University Hospital Aachen, Germany
| | - Marcus J Schultz
- Dept of Intensive Care, Amsterdam UMC, location AMC, Amsterdam, The Netherlands.,Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand
| | - Leo Heunks
- Dept of Intensive Care, Amsterdam UMC, location VUMC, Amsterdam, The Netherlands
| | - Raffaele Scala
- Pulmonology and Respiratory Intensive Care Unit, S. Donato Hospital, Arezzo, Italy
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396
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Turton P, ALAidarous S, Welters I. A narrative review of diaphragm ultrasound to predict weaning from mechanical ventilation: where are we and where are we heading? Ultrasound J 2019; 11:2. [PMID: 31359260 PMCID: PMC6638615 DOI: 10.1186/s13089-019-0117-8] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 02/08/2019] [Indexed: 12/19/2022] Open
Abstract
Background The use of ultrasound to visualize the diaphragm is well established. Over the last 15 years, certain indices of diaphragm function, namely diaphragm thickness, thickening fraction and excursion have been established for mechanically ventilated patients to track changes in diaphragm size and function over time, to assess and diagnose diaphragmatic dysfunction, and to evaluate if these indices can predict successful liberation from mechanical ventilation. In the last 2 years, three meta-analyses and a systematic review have assessed the usability of diaphragmatic ultrasound to predict successful weaning. Since then, further data have been published on the topic. Conclusions The aim of this narrative review is to briefly describe the common methods of diaphragmatic function assessment using ultrasound techniques, before summarizing the major points raised by the recent reviews. A narrative summary of the most recent data will be presented, before concluding with a brief discussion of future research directions in this field.
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Affiliation(s)
- Peter Turton
- Critical Care Unit, Royal Liverpool University Hospital, Liverpool, UK. .,Institute of Aging and Chronic Disease, University of Liverpool, Liverpool, UK.
| | - Sondus ALAidarous
- Critical Care Unit, Royal Liverpool University Hospital, Liverpool, UK.,Institute of Infection and Global Health, University of Liverpool, Liverpool, UK
| | - Ingeborg Welters
- Critical Care Unit, Royal Liverpool University Hospital, Liverpool, UK.,Institute of Aging and Chronic Disease, University of Liverpool, Liverpool, UK
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Evans D, Shure D, Clark L, Criner GJ, Dres M, de Abreu MG, Laghi F, McDonagh D, Petrof B, Nelson T, Similowski T. Temporary transvenous diaphragm pacing vs. standard of care for weaning from mechanical ventilation: study protocol for a randomized trial. Trials 2019; 20:60. [PMID: 30654837 PMCID: PMC6337771 DOI: 10.1186/s13063-018-3171-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Accepted: 12/31/2018] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Mechanical ventilation (MV) is a life-saving technology that restores or assists breathing. Like any treatment, MV has side effects. In some patients it can cause diaphragmatic atrophy, injury, and dysfunction (ventilator-induced diaphragmatic dysfunction, VIDD). Accumulating evidence suggests that VIDD makes weaning from MV difficult, which involves increased morbidity and mortality. METHODS AND ANALYSIS This paper describes the protocol of a randomized, controlled, open-label, multicenter trial that is designed to investigate the safety and effectiveness of a novel therapy, temporary transvenous diaphragm pacing (TTVDP), to improve weaning from MV in up to 88 mechanically ventilated adult patients who have failed at least two spontaneous breathing trials over at least 7 days. Patients will be randomized (1:1) to TTVDP (treatment) or standard of care (control) groups. The primary efficacy endpoint is time to successful extubation with no reintubation within 48 h. Secondary endpoints include maximal inspiratory pressure and ultrasound-measured changes in diaphragm thickness and diaphragm thickening fraction over time. In addition, observational data will be collected and analyzed, including 30-day mortality and time to discharge from the intensive care unit and from the hospital. The hypothesis to be tested postulates that more TTVDP patients than control patients will be successfully weaned from MV within the 30 days following randomization. DISCUSSION This study is the first large-scale clinical trial of a novel technology (TTVDP) aimed at accelerating difficult weaning from MV. The technology tested provides the first therapy directed specifically at VIDD, an important cause of delayed weaning from MV. Its results will help delineate the place of this therapeutic approach in clinical practice and help design future studies aimed at defining the indications and benefits of TTVDP. TRIAL REGISTRATION ClinicalTrials.gov, NCT03096639 . Registered on 30 March 2017.
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Affiliation(s)
- Douglas Evans
- Lungpacer Medical Incorporated, Burnaby, BC, Canada.,Lungpacer Medical, 260 Sierra Drive, Exton, PA, 19335, USA
| | | | - Linda Clark
- Lungpacer Medical Incorporated, Burnaby, BC, Canada
| | - Gerard J Criner
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Martin Dres
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique and AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Service de Pneumologie et Réanimation Médicale du Département R3S, Paris, France
| | - Marcelo Gama de Abreu
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Franco Laghi
- Division of Pulmonary and Critical Care Medicine, Hines Veterans Affairs Hospital Hines, Loyola University, Maywood, IL, USA
| | - David McDonagh
- Departments of Anesthesiology and Pain Management, Neurological surgery, Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Basil Petrof
- Meakins-Christie Laboratories, and Translational Research in Respiratory Diseases Program, McGill University Health Centre and Research Institute, Montreal, QC, Canada
| | | | - Thomas Similowski
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique and AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Service de Pneumologie et Réanimation Médicale du Département R3S, Paris, France.
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398
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Goligher EC, Brochard LJ, Reid WD, Fan E, Saarela O, Slutsky AS, Kavanagh BP, Rubenfeld GD, Ferguson ND. Diaphragmatic myotrauma: a mediator of prolonged ventilation and poor patient outcomes in acute respiratory failure. THE LANCET RESPIRATORY MEDICINE 2019; 7:90-98. [DOI: 10.1016/s2213-2600(18)30366-7] [Citation(s) in RCA: 72] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 08/04/2018] [Accepted: 08/21/2018] [Indexed: 12/19/2022]
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399
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Johnson RW, Ng KWP, Dietz AR, Hartman ME, Baty JD, Hasan N, Zaidman CM, Shoykhet M. Muscle atrophy in mechanically-ventilated critically ill children. PLoS One 2018; 13:e0207720. [PMID: 30566470 PMCID: PMC6300323 DOI: 10.1371/journal.pone.0207720] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Accepted: 11/05/2018] [Indexed: 01/31/2023] Open
Abstract
Importance ICU-acquired muscle atrophy occurs commonly and worsens outcomes in adults. The incidence and severity of muscle atrophy in critically ill children are poorly characterized. Objective To determine incidence, severity and risk factors for muscle atrophy in critically ill children. Design, setting and participants A single-center, prospective cohort study of 34 children receiving invasive mechanical ventilation for ≥48 hours. Patients 1 week– 18 years old with respiratory failure and without preexisting neuromuscular disease or skeletal trauma were recruited from a tertiary Pediatric Intensive Care Unit (PICU) between June 2015 and May 2016. We used serial bedside ultrasound to assess thickness of the diaphragm, biceps brachii/brachialis, quadriceps femoris and tibialis anterior. Serial electrical impedance myography (EIM) was assessed in children >1 year old. Medical records were abstracted from an electronic database. Exposures Respiratory failure requiring endotracheal intubation for ≥48 hours. Main outcome and measures The primary outcome was percent change in muscle thickness. Secondary outcomes were changes in EIM-derived fat percentage and “quality”. Results Of 34 enrolled patients, 30 completed ≥2 ultrasound assessments with a median interval of 6 (IQR 6–7) days. Mean age was 5.42 years, with 12 infants <1 year (40%) and 18 children >1 year old (60%). In the entire cohort, diaphragm thickness decreased 11.1% (95%CI, -19.7% to -2.52%) between the first two assessments or 2.2%/day. Quadriceps thickness decreased 8.62% (95%CI, -15.7% to -1.54%) or 1.5%/day. Biceps (-1.71%; 95%CI, -8.15% to 4.73%) and tibialis (0.52%; 95%CI, -5.81% to 3.40%) thicknesses did not change. Among the entire cohort, 47% (14/30) experienced diaphragm atrophy (defined a priori as ≥10% decrease in thickness). Eighty three percent of patients (25/30) experienced atrophy in ≥1 muscle group, and 47% (14/30)—in ≥2 muscle groups. On multivariate linear regression, increasing age and traumatic brain injury (TBI) were associated with greater muscle loss. EIM revealed increased fat percentage and decreased muscle “quality”. Conclusions and relevance In children receiving invasive mechanical ventilation, diaphragm and other skeletal muscle atrophy is common and rapid. Increasing age and TBI may increase severity of limb muscle atrophy. Prospective studies are required to link muscle atrophy to functional outcomes in critically ill children.
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Affiliation(s)
- Ryan W. Johnson
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri, United States of America
| | - Kay W. P. Ng
- Department of Neurology, Washington University School of Medicine, St. Louis, Missouri, United States of America
- Department of Medicine, National University, Singapore
| | - Alexander R. Dietz
- Department of Neurology, Washington University School of Medicine, St. Louis, Missouri, United States of America
- Blue Sky Neurology, Englewood, Colorado, United States of America
| | - Mary E. Hartman
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri, United States of America
| | - Jack D. Baty
- Division of Biostatistics, Washington University School of Medicine, St. Louis, Missouri, United States of America
| | - Nausheen Hasan
- St. Louis Children’s Hospital, St. Louis, Missouri, United States of America
| | - Craig M. Zaidman
- Department of Neurology, Washington University School of Medicine, St. Louis, Missouri, United States of America
| | - Michael Shoykhet
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri, United States of America
- Children’s Research Institute, Children’s National Medical Center, Washington, District of Columbia, United States of America
- * E-mail:
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400
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Kataoka J, Kuriyama A, Norisue Y, Fujitani S. Proportional modes versus pressure support ventilation: a systematic review and meta-analysis. Ann Intensive Care 2018; 8:123. [PMID: 30535648 PMCID: PMC6288104 DOI: 10.1186/s13613-018-0470-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Accepted: 12/04/2018] [Indexed: 12/29/2022] Open
Abstract
Background Proportional modes (proportional assist ventilation, PAV, and neurally adjusted ventilatory assist, NAVA) could improve patient–ventilator interaction and consequently may be efficient as a weaning mode. The purpose of this systematic review is to examine whether proportional modes improved patient–ventilator interaction and whether they had an impact on the weaning success and length of mechanical ventilation, in comparison with PSV.
Methods We searched PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials from inception through May 13, 2018. We included both parallel-group and crossover randomized studies that examined the efficacy of proportional modes in comparison with PSV in mechanically ventilated adults. The primary outcomes were (1) asynchrony index (AI), (2) weaning failure, and (3) duration of mechanical ventilation. Results We included 15 studies (four evaluated PAV, ten evaluated NAVA, and one evaluated both modes). Although the use of proportional modes was not associated with a reduction in AI (WMD − 1.43; 95% CI − 3.11 to 0.25; p = 0.096; PAV—one study, and NAVA—seven studies), the use of proportional modes was associated with a reduction in patients with AI > 10% (RR 0.15; 95% CI 0.04–0.58; p = 0.006; PAV—two studies, and NAVA—five studies), compared with PSV. There was a significant heterogeneity among studies for AI, especially with NAVA. Compared with PSV, use of proportional modes was associated with a reduction in weaning failure (RR 0.44; 95% CI 0.26–0.75; p = 0.003; PAV—three studies) and duration of mechanical ventilation (WMD − 1.78 days; 95% CI − 3.24 to − 0.32; p = 0.017; PAV—three studies, and NAVA—two studies). Reduced duration of mechanical ventilation was found with PAV but not with NAVA. Conclusion The use of proportional modes was associated with a reduction in the incidence with AI > 10%, weaning failure and duration of mechanical ventilation, compared with PSV. However, reduced weaning failure and duration of mechanical ventilation were found with only PAV. Due to a significant heterogeneity among studies and an insufficient number of studies, further investigation seems warranted to better understand the impact of proportional modes. Clinical trial registration PROSPERO registration number, CRD42017059791. Registered 20 March 2017 Electronic supplementary material The online version of this article (10.1186/s13613-018-0470-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jun Kataoka
- Department of Pulmonary and Critical Care Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, 3-4-32 Todaijima, Urayasu, 2790001, Japan.
| | - Akira Kuriyama
- Emergency and Critical Care Center, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki, Okayama, 7108602, Japan
| | - Yasuhiro Norisue
- Department of Pulmonary and Critical Care Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, 3-4-32 Todaijima, Urayasu, 2790001, Japan
| | - Shigeki Fujitani
- Department of Emergency Medicine and Critical Care Medicine, St. Marianna University, 2-16-1 Sugao, Miyamae-ku, Kawasaki, 2168511, Japan
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